Color April-June 2008.pub

preventive medicine:the science and practice of HEALTH protection

April – June 2008Perspective 1MG Russell J. Czerw

Chemical Defense Against Blood-Feeding Arthropods 4by Disruption of Biting BehaviorCOL Mustapha Debboun, MS, USA; Jerome A. Klun, PhD

The Deployed Warfighter Protection Research Program: 9Finding New Methods to Vanquish Old FoesCAPT Stanton E. Cope, MSC, USN; COL (Ret) Daniel A. Strickman, MS, USA; Graham B. White, PhD

Support of Far-Forward Disease Surveillance Operations with Deployable, 21Real-Time Vector-Borne Disease Agent Analytic CapabilityCol James A. Swaby, BSC, USAF; James C. McAvin

Level III Preventive Medicine in a Counterinsurgency Environment 25MAJ Derek J. Licina, MS, USA

Preparing the Force for the Chemical, Biological, Radiological, and 36High Yield Explosives Battlefield; Today and TomorrowLTC Gary Matcek, MS, USA; Scott Crail, MS; SFC Courtney Moore, USA; James Bernardo

The Army Preventive Medicine Specialist in the 40Medical Education and Training Campus EraLTC Dennis B. Kilian, MS, USA; SFC Roye L. Patton, USA; HMCS William Adams, USN

Malaria Risk Assessment for the Republic of Korea 46Based on Models of Mosquito DistributionDesmond H. Foley, PhD; et al

The US Air Force Aerial Spray Unit: A History of 54Large Area Disease Vector Control Operations, WWII Through KatrinaMaj Mark Breidenbaugh, BSC, USAFR; Maj Karl Haagsma, BSC, USAFR

Evolution of the Army Hearing Program 62MAJ Scott McIlwain, MS, USA; et al

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea 67LTC William J. Sames, MS, USA; Heung-Chul Kim, PhD; COL (Ret) Terry A. Klein, MS, USA

Health Implications of Occupational Environmental Health Sampling 74Coleen Weese, MD, MPH

LTG Eric B. SchoomakerThe Surgeon GeneralCommander, US Army Medical Command

MG Russell J. CzerwCommanding GeneralUS Army Medical Department Center and School

April – June 2008 The Army Medical Department Center & School PB 8-08-4/5/6

0809205

GEORGE W. CASEY, JRGeneral, United States Army

Chief of Staff

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JOYCE E. MORROW

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April – June 2008 1

The Department of Defense defines the term forcemultiplier as

A capability that, when added to and employed by acombat force, significantly increases the combatpotential of that force and thus enhances the probabilityof successful mission accomplishment.1

Military planners, strategists, and analysts generallyuse the term as related to factors such as technology,intelligence, training, tactics, terrain, etc. However,over the last century, the science and practice ofpreventive medicine in the military has itself becomean increasingly significant force multiplier.Nonetheless, the contributions of preventive medicineare often not recognized as such following successfulmilitary campaigns. On the other hand, the absence ofeffective measures are immediately apparent, for allthe wrong reasons. In early 1943, following theextremely difficult and costly opening campaignsagainst the Japanese in Paupau New Guinea, GeneralMacArthur was told that 72% of the combined Alliedforce was sick, 60% with malaria. His brief responseclearly captures the indisputable value of preventivemedicine as a force multiplier:

Doctor, this will be a long war if for every division Ihave facing the enemy, I must count on a seconddivision in hospital with malaria and a third divisionconvalescing from this debilitating disease.2

General MacArthur’s remarks were indicative of theincreasing awareness among top level commanders ofpreventive medicine’s vital role in combat operations.Over time, that evolving realization has resulted intop-down emphasis, policies, and regulations toinstitutionalize preventive medicine as an integral partof the planning and execution of training andoperational deployments.3

Fortunately, increasing awareness of preventivemedicine’s role in the improvement of human healthhas not been limited to the military. Governments at alllevels have established policies and regulatoryframeworks, committed resources, and conductedpublic awareness programs targeted at the improve-ment of the overall health of their populations.

As with most areas of medical science, the practice ofpreventive medicine transcends the military-civilian

boundary. In this regard, military medicine is veryfortunate to have been both beneficiary of andcontributor to its progress over the years. This issue ofthe AMEDD Journal focuses on the science andpractice of preventive medicine from a militaryperspective, while featuring articles that reflect themutual benefits to both sides from the overlap ofknowledge, practices, and purpose.

COL Mustapha Debboun and Dr Jerome Klun openthis issue with a stimulating article exploring thebackground and current science of synthetic organicchemical arthropod repellents. As related in theirarticle, the world’s first truly effective insect repellentwas developed in a collaborative effort of the USArmy and the Department of Agriculture, which beganduring World War II. They detail the chemistry ofwhat are currently the 3 most effective compounds andthe experiments that explore the mechanism of theirrepellency. This research is a prime example of thetype of partnerships between military and civilian thatare so effective in the science of preventive medicine.

The importance of such collaboration to the military isdemonstrated in the next article. CAPT Stanton Cope,USN, and his coauthors describe the DeployedWarfighter Protection research program (DWFP), aninnovative, forward-thinking DoD effort to tap intononmilitary talent and resources in the search for newways of protecting our deployed personnel from

PerspectiveMajor General Russell J. Czerw

2 www.cs.amedd.army.mil/references_publications.aspx

vector-borne diseases. The DWFP provides funding toboth government and nongovernment research projectswhich are exploring new and better ways of troopprotection. Although the DWFP is a recent initiative,the results have been an ever-increasing level ofknowledge in the sciences involved, with attendantimproved sophistication in techniques and procedures,as well as a number of products created specifically fordealing with the insect threat.

Knowledge of the specific disease threats in adeployment area is critical in determining the type ofpreventive medicine measures which are required forforce protection. Current data may or may not beavailable, or accurate, and obtaining such informationhas always been a time-consuming, multifacetedundertaking. Col James Swaby, USAF, and JamesMcAvin have been involved in the development of asystem that will allow forward deployed units to assessthe local threat of vector-borne diseases in real-time,without dependence on far-away laboratories. Theirarticle details the Vector Surveillance AnalyticSystem, a vitally important advancement in our arsenalof weapons to protect the health of our Warriors.

Since the end of combat in Korea in 1953, thecharacter of military conflict has evolved from theclassic model of conventional warfare between armiesinto operations against shadowy, low-tech, looselyorganized insurgencies. MAJ Derek Licina hascontributed a profound, well-researched article thatspotlights how counterinsurgency operations are rarelywon with overwhelming firepower alone, but withother operations targeting the conditions whichprovide the base of support for those insurgents.Preventive medicine can and should be a majorcomponent of such operations. This important article isdeveloped using the history of such conflicts combinedwith extensive experience with current counter-insurgency operations in the middle east. MAJ Licinaproposes thoughtful changes in doctrine, organization,and training of Army preventive medicine designed tosignificantly improve its capability to directlycontribute to long-term counterinsurgency operations.The principles and science of preventive medicine mayindeed be the “secret weapon” that will effect afavorable shift in both the physical and ideologicalenvironments of modern military conflict.

An ironic reality of the shift in the character of militaryoperations to the fluid, ill-defined, counterinsurgencyenvironment is the increased potential for the use of

unconventional weapons, at almost any time or place.Insurgents have no political, moral, or ethicallimitations to their actions, and are not concernedabout repercussions. Their lack of sophisticationincreases the potential danger that chemical,biological, radiological, or high yield explosives(CBRNE) could be used in almost any scenario,including accidentally during transport or storage.LTC Gary Matcek and his team from the CBRNESciences Branch have contributed an article describingboth the training of medical personnel to cope with theevolving threats, and the development of new toolsand protocols to enhance their capabilities. The dangerrepresented by CBRNE weapons is not limited to thebattlefield or military installation. The importance ofthis component of preventive health science cannot beoveremphasized.

One of the many changes stemming from the latestround of the Base Closure and RealignmentCommittee activity is the consolidation of a significantportion of Army, Navy, and Air Force medical enlistedtraining at Fort Sam Houston. The Medical Educationand Training Campus is a result of that initiative. LTCDennis Kilian and his coauthors describe in detail themeticulous collaborative process that resulted in theplan for consolidated training of enlisted preventivemedicine personnel. Their article provides insight intothe plans for both the academic syllabus changes andthe personnel and physical infrastructure requirementsnecessary to make the concept a reality.

Even after years of intensive research andcountermeasures, malaria remains one of the mostpersistent, and deadly, vector-borne health threats inthe world today. Assessment of the risk of malaria in agiven geographic region is the first step in planning toaddress its threat. Since malaria is transmitted solelyby several species of the Anopheles mosquito, identi-fication of the actual and potential distribution of thosespecies in a geographic area could be a valuable tool inthe development of the risk assessment. Dr DesmondFoley and his coauthors present a new approach theydeveloped to model the distribution of malaria vectors,using the US military installations on the Koreanpeninsula as the areas of interest. Their detailed andclearly presented article demonstrates theimmeasurable value of the symbiotic relationship ofmilitary and civilian resources and talent in the waragainst vector-borne disease. The increase in thenumber and capabilities of data-gathering sources,

Perspective


THE ARMY MEDICAL DEPARTMENT JOURNAL

combined with increasingly sophisticated analysis andmodeling techniques are powerful weapons in thehands of dedicated professionals such as Dr Foley andhis team. Innovative work such as this will continue toevolve, to the benefit of everyone, everywhere.

In 1918, an airplane was used to distribute insecticidefor the first time.4 Since then, aerial application ofpesticides has been an invaluable tool for bothagriculture and preventive medicine. USAFR MajMark Breidenbaugh and Maj Karl Haagsma havewritten an excellent article about one of today’s USmilitary aerial spray capabilities, the USAF AerialSpray Unit (AFASU). Their article traces the longhistory of this versatile unit, and describes its multipleroles in responding to both military and civilianrequirements throughout the United States andoverseas. The article focuses on large area insectproblems, especially mosquitoes, which become veryserious in the aftermath of hurricanes. The AFASU’sresponse to Hurricane Katrina in Louisiana is detailedas an illustration of the extensive planning and closecooperation between the military and civilianpreventive medicine authorities that is required toensure a timely and effective response. The articleprovides an informative overview of this uniquecapability, and the high level of professionalism ofthose who perform the vitally important missions.

Hearing is something that most of us take for granted,yet it is one of the most important, and mostvulnerable, of our senses in a survival situation,including combat. Not surprisingly, some loss ofhearing is one of the most common conditions amongmilitary veterans. Extremely loud noise is anunavoidable part of military operations, but hearingloss in not inevitable. In their informative article, MAJScott McIlwain and his coauthors provide an overviewof the conditions that contribute to hearing loss, andstatistics that demonstrate the surprising extent of thatloss among military members today. They detail thevarious research, techniques, and equipment used toaddress this hazard, which has resulted in the ArmyHearing Program, the current structure designed toprovide effective loss prevention services at alllocations, including forward deployed areas. Thisarticle contains important information which should beof interest to everyone, military or civilian.

Despite all of our efforts since the Korean War,malaria and Japanese encephalitis remain valid threatsin Korea. LTC William Sames and his coauthors have

contributed an important article describing thesituation faced by our Warriors and their families, aswell as the Korean population as a whole, and theongoing efforts to control the threat posed by the twodiseases. The article is packed with information aboutthe cycles of infection and transmission for eachdisease, the hosts that harbor the pathogens, and thecooperative relationships between the US militarypreventive medicine specialists and the various Koreanagencies in actions to address these threats. As clearlyillustrated throughout the articles in this issue, thereare no boundaries to preventive medicine’s importanceto health, whether civilian, military, or national.

At first look, evaluation of the health of Soldiersreturning from deployment would seemstraightforward—a physical examination focused oninjuries and whatever illnesses the Soldier may haveincurred during the deployment period. However, theextent of follow-on illnesses that are a result ofdeployments has been recognized only relativelyrecently. Dr Colleen Weese’s article is an eye-openinglook at the complexities involved in quantifying theproblem of environmental hazards, and the measuresimplemented to address those hazards for ourdeploying Warriors. The results include a program thatcollects and catalogues worldwide environmental datafor area assessments, a system that maintains theexposure history of military personnel throughout theirlifetime, and formalized requirements for the samplingand evaluation of air, water, and soil from thedeployment area. Most importantly, significantexposures must now be documented in the individualmedical record. Dr Weese’s article demonstrates theresponsiveness of the military medical system, and theextent of our efforts to protect the health of ourdedicated Warriors, whether immediate or long-term.

REFERENCES

1. Joint Publication 1-02: DoD Dictionary of Militaryand Associated Terms. Washington, DC: Joint Staff,US Dept of Defense; March 4, 2008. Available at:h t tp : / / www.d t i c .mi l /do c t r ine / j e l /ne w_p ubs /jp1_02.pdf.

2. Coates JB. Communicable Diseases: Malaria.Washington, DC: US Dept of the Army; 1963.Preventive Medicine in World War II; vol 6:2.

3. Gates MB. Prevention is the best way to health. ArmyMed Dept J. April-June 2006:3-6.

4. http://entweb.clemson.edu/pesticid/history.htm


In military operations, vector-borne diseases andassociated discomfort caused by biting arthropods canbe largely prevented with proper use of personalprotective measures, particularly arthropod repellents.When appropriately applied, such repellents are thefirst line of defense against a wide range of arthropod-borne pathogens and will preserve the fighting strengthof the troops. The bites of arthropods transmit many ofthe disease-causing agents that cause our military themost trouble. These diseases can take Soldiers out ofthe action, make them miserably sick, or even killthem. In addition, the diseases and the arthropods thattransmit them are as much of a threat during routinefield training exercises or humanitarian/disasterassistance operations as during actual combat.

Arthropod repellents provide military commanderswith a quick and inexpensive measure to protect theforce in any military situation, no matter how quicklythe unit is involved in action. They can be appliedeffectively to prevent any arthropod-borne disease,whether or not surveillance has identified thepathogen. Arthropod repellents are often the onlymeans of protection against arthropod-borne diseases in combat environmentswhen vector control measures are notpossible, or when the speed of militarydevelopments prevents the use ofchemoprophylaxis or vaccines. In addition,commanders will be able to minimizeincidence of any vector-borne disease,providing a tactical advantage against anunprotected enemy force which does nothave the benefit of an effective, long-lasting arthropod repellent.

The Department of Defense (DoD) InsectRepellent System is available for use by allmilitary personnel to prevent arthropod-borne pathogens that cause diseases suchas malaria, leishmaniasis, trypanosomiasis,scrub typhus, West Nile fever, and Lyme

disease. As shown in Figure 1, the repellent systemconsists of 3 components: permethrin on uniforms(and bed nets), deet on exposed skin, and proper wearof the uniform. When used properly, this system willprevent disease, pain, and the annoyance caused bybites of insects such as mosquitoes, sand flies, ticks,and chiggers. The repellent system is critical to theArmy Medical Regiment’s motto to “Conserve theFighting Strength,” and is a mission essential taskcontained in Soldier Training Publication 21-1.1

Further, DoD policy mandates that every Soldier,Sailor, Airman, and Marine must strictly follow theguidelines and methods of the repellent system. Detailsare found in the Armed Forces Pest ManagementBoard Technical Guide 36 2 and in the US ArmyCenter for Health Promotion and Preventive Medicinefact sheet on the DoD Insect Repellent System3 and atthe US Army Medical Department Center and Schooldeployment training portal website.4

DoD operates the Walter Reed Army Institute ofResearch and 5 other US overseas laboratories: ArmedForces Research Institute of Medical Sciences,

Chemical Defense Against Blood-FeedingArthropods by Disruption of Biting Behavior

COL Mustapha Debboun, MS, USAJerome A. Klun, PhD

Permethrinon

Uniform

Deet onExposed

Skin

ProperlyWorn

Uniform

A BasicTraining

Task

DoD Policy

CriticalFor YourHealth

Figure 1. The DoD Insect Repellent System


Bangkok, Thailand; US Army Medical Research Unit-Kenya, Nairobi; Naval Medical Research CenterDetachment, Lima, Peru; Naval MedicalResearch Unit-2, Jakarta, Indonesia; and theNaval Medical Research Unit 3, Cairo,Egypt. These resources, combined withcollaborations with the US Department ofAgriculture, Agricultural Research Servicesand the Australian Army Malaria Institute,place the US military in an outstandingposition to test and evaluate repellents inthe laboratory and in the field againstvectors of many disease-causing pathogens.

All haematophagous arthropod pests suchas female mosquitoes, sand flies, mites,black flies, and ticks require a blood meal toproduce eggs and complete their life cycles.Males do not blood feed. Thus, thankfully,only half of the population of sucharthropod species are biters and blood-feeders. The biting activity of females iscomplex and they may preferably feed onlyon specific hosts such as reptiles or birds. Insome species, the females may havemultiple hosts which often include humans.It is these arthropod species of blood-feeders that are simply annoying, orrepresent vectors of dangerous pathogenicdiseases that can injure or kill. The diseasesvectored are many and include malaria,leishmaniasis, dengue, yellow fever, WestNile fever, Lyme borreliosis, and spottedfevers. Throughout history, humans havestruggled against the blood-feedingarthropods, and the struggle continues todayin full force.

Synthetic organic chemicals have proven effective ininterfering with arthropod blood-feeding behavior, andcan offer personal protection against the bites ofnuisance pests and disease vectors by topicalapplication to skin or clothing.5,6 Several notablyeffective synthetic repellent compounds, the structuresof which are shown in Figure 2, are: N,N-diethyl-3-methylbenzamide (deet) (structure 1), 2-(2-hydroxyethyl)-1-piperidinecarboxylic acid 1-methylpropylester (variously known as KBR3023,Bayrepel, Picaridin or Icaridin) (structure 2), and (1S,2’S)-methylpiperidinyl-3-cyclohexene-1-carboxamide(SS220) (structure 3). Each of these repellentcompounds has an interesting developmental history,

and each is known to interfere with arthropod blood-feeding behavior.

Deet was developed in 1954 as an outgrowth of anintensive systematic chemical search for syntheticpersonal-protection chemicals that began during WorldWar II with a collaborative effort involving the USDepartment of the Army and the Department ofAgriculture (USDA), Bureau of Entomology and PlantQuarantine.7,8 In the years following its development,deet became the standard personal protection repellentproduct of choice for use by the general public andmilitary organizations worldwide. The use of deet wasso universal that it became an anthropogenic organicchemical pollutant in many bodies of surface watersranging from the Tama River in Japan and the RhineRiver in Germany, to the waters of the North Sea.9

N

O

CH3

CH3N

OH

CH3N

OH

N

O

CH3

H HN

O

CH3

NOH

O

O H

1S, 2'S 1R, 2'S

1S, 2'R1R, 2'R

12

1

3

2

4

5 6

12

3 4

5 6

Figure 2. Chemical structure of Deet, KBR3023, and the diastereo-isomers of AI3-37220.


In 1996, the discovery of KBR 3023 was announced,10

and the racemic compound was subsequentlycommercialized worldwide by Bayer. This compoundcontains 2 asymmetric centers as indicated in Figure 2,structure 2, and, therefore, the racemic compound iscomposed of 4 diastereoisomers. Preliminary workwith the yellow fever mosquito, Aedes aegypti,indicated that the 1R, 2’S diastereoisomer of KBR3023 (RS-KBR 3023) was the most effective indeterring mosquito biting.11 The KBR 3023 efficacymight be improved by using the most biologicallyactive form of its 4 stereoisomers. Independent fieldand laboratory bioassays with the racemic KBR 3023generally show that it effectively reduced bites ofmosquitoes, sand flies, noseeums, and ticks, andeffectiveness of the compound was often equivalent todeet.12-18 In human volunteer laboratory bioassays withAe. aegypti, we found that deet and SS220 wereequally effective and more effective, respectively, thanKBR 3023 in suppressing its biting.19 The 3 repellentcompounds were equally effective against Anophelesstephensi. Internet searches indicate that Lanxess andS.C. Johnson, respectively, are actively involved inmarketing this compound.*

The racemic 2-methylpiperidinyl-3-cyclohexene-1-carboxamide was first identified as an insect repellentby McGovern et al,20 and the USDA assigned thecompound the code number AI3-37220. Like KBR3023, AI3-37220 contained 2 asymmetric centers, andachiral synthesis yielded a racemic mixture of 1S, 2'S,1R, 2’S, 1S, 2’R and 1R, 2’R diastereoisomers (Figure2, structures 3, 4, 5, and 6). The racemic mixtureproved to be effective against the biting behavior of awide variety of blood-feeding arthropods.21-29

A study of the stereoisomers of AI-37220 showed thatthe 1S, 2'S stereoisomer (SS220) was the mosteffective isomer of the four in reducing bites by Ae.aegypti,30 and it is surmised that enhanced repellenteffects can be realized through specific formulation ofthis most active stereoisomer. Toxicological testsindicate that SS220 is biologically pacific andamenable to dermal application to defend humansagainst many blood-feeding arthropods.

Deet, KBR 3023, and SS220 are among the mosteffective synthetic repellent compounds for protection

against nuisance and blood-feeding arthropods thatvector human diseases. Despite the widespreadknowledge of the protective qualities of these repellentcompounds,17,19,31 there was, until recently, littleinformation available on how the compoundsmechanistically affect whole organism behavior andthereby suppresses the biting. A series of behavioraltests32 with Ae. aegypti, An. stephensi mosquitoes andthe sand fly, Phlebotomus papatasi in the presence ofdeet, SS220, and KBR 3023 topically applied to theskin of human volunteers showed that the insects weredeterred from feeding on and repelled from surfacesemanating the compounds. When offered a 12 cm2 or24 cm2 area of skin, one half treated with compoundand one half untreated, the insects fed almostexclusively on untreated skin. The sand flies andmosquitoes did not at any time physically contactchemically-treated surfaces. When treated anduntreated skin areas were covered with cloth, insectslanded and bit only through cloth covering untreatedskin. These observations provided evidence that thechemicals deterred feeding and repelled insects fromtreated surfaces primarily as a result of olfactorysensing. When cloth, one half untreated and the otherhalf treated with chemical, was placed over untreatedskin, insects only touched and specifically bit throughthe untreated cloth. This showed that the activity of thechemicals does not involve a chemical skin inter-action. In the presence of any of the 3 repellentcompounds, no matter how presented to the insects,overall population biting activity was reduced by aboutone-half relative to the controls. The research indicatesthat the protection afforded by deet, SS220, and KBR3023 against the insect feeding upon humans ismechanistically a combined consequence of feedingdeterrent and repellent effects of the compounds.

The behavioral studies clearly showed that all 3compounds were perceived by olfactory sensing, and itwas curious that these man-made and structurallydifferent compounds profoundly influenced the blood-feeding behavior of Ae. aegypti, An. stephensi, and P.papatasi in similar ways. Natarajan et al 11 conductedcomputer-assisted stereochemical structure-activityrelationship and molecular overlay studies of SS220,KBR 3023, and deet to show that forms of compoundspossessing the highest levels of repellent and feedingdeterrent activity each have similar three-dimensionalstructural motifs. This suggests that thebiomacromolecule(s) responsible for the olfactory

*Websites: http://www.bayrepel.com/bre/en/index.phphttp://www.autan.com/nqcontent.cfm?a_id=1

Chemical Defense Against Blood-Feeding Arthropods by Disruption of Biting Behavior



recognition of the compounds in the insects is (are)specifically sensitive to the active space-matchingqualities of SS220, RS-KBR 3023, and deet. Thedevelopment of new behaviorally-active chemicaltools for protection of humans against blood-feedingdisease vectors will ultimately depend upon the extentto which the fundamental nature of this process isunderstood.

REFERENCES

1. Soldier Training Publication 21-1, Soldier’s Manualof Common Tasks, Level 1. Washington, DC: USDept of the Army; 14 December 2007.

2. AFPMB Technical Guide No. 36: Personal ProtectiveMeasures Against Insects And Other Arthropods OfMilitary Significance. Washington, DC: ArmedForces Pest Management Board, US Dept of Defense;April 18, 2002. Available at: http://www.afpmb.org/coweb/guidance_targets/ppms/TG36/TG36.pdf.

3. USACHPPM Fact Sheet: DoD Insect RepellentSystem. Aberdeen Proving Ground, MD: US ArmyCenter for Health Promotion and PreventiveMedicine. June 2007. Available at: http://chppm-w w w . a p g e a . a r m y . m i l / d o c u m e n t s / F A C T /D O D I n s e c t R e p e l l e n t S y s t e m J u s t h e F a c t s -June2007.pdf.

4. DoD Insect Repellent System. Deployment RelevantTraining. US Army Medical Department Center andSchool Deployment Portal website. Available at:http://www.cs.amedd.army.mil/deployment2.aspx#.

5. Philip CB, Paul JR, Sabin AB. Dimethyl phthalate asa repellent in control of Phlebotomus pappataci orsand fly fever. War Medicine. 1944;6:27-33.

6. Strickman D, Miller ME, Lee KW, et al. Successfulentomological intervention against Anophelessinensis, limiting transmission of Plasmodium vivaxto American Soldiers in the Republic of Korea. Kor JEntomol. 2001;31:189-195.

7. McCabe ET, Barthel WF, Gertler SI, Hall SD. InsectRepellents. III. N, N-diethylamides. J Org Chem.1954;19:493-498.

8. Cushing EC. History of Entomology in World War II.Baltimore, MD: The Lord Baltimore Press Inc; 1957.

9. Knepper TP. Analysis and mass spectrometriccharacterization of the insect repellent Bayrepel andits main metabolite Bayrepel-acid. J Chromatogr.2004;1046(1-2):159-166.

10. Boeckh J, Breer H, Geier M, et al. Acylated 1,3-aminopropanols as repellents against bloodsuckingarthropods. Pestic Sci. 1996;48(4):359-373.

11. Natarajan R, Basak SC, Balaban AT, Klun JA,Schmidt WF. Chirality index, molecular overlay andbiological activity of diastereoisomeric mosquitorepellents. Pest Manag Sci. 2005;61(12):1193-1201.

12. Badolo A, Ouédraogo AP, Ilboudo-Sanogo E,Costantini C. Evaluation of the sensitivity of Aedesaegypti and Anopheles gambiae complex mosquitoesto two insect repellents: DEET and KBR 3023. TropMed Int Health. 2004;9(3):330-334.

13. Carpenter S, Eyres K, McEndrick I, et al. Repellentefficiency of BayRepel against Culicoidesimpunctatus (Diptera: Ceratopogonidae). ParasitolRes. 2005;95(6):427-429.

14. Costantini C, Badolo A, Ilboudo-Sanogo E. Fieldevaluation of the efficacy and persistence of insectrepellents deet, IR3535, and KBR 3023 againstAnopheles gambiae complex and other Afrotropicalvector mosquitoes. Trans R Soc Trop Med Hyg.2004;98(11):644-652.

15. Perrotey S, Madulo-Leblond G, Pesson B. Laboratorytesting of the insect repellent KBR 3023 againstPhlebotomus duboscqi (Diptera: Psychodidae).Parasitol Res. 2002;88(7):712-713.

16. Yap HH, Jahangir K, Zairi J. Field efficacy of fourinsect repellent products against vector mosquitoes ina tropical environment. J Am Mosq Control Assoc.2000;16(3):241-244.

17. Frances SP, Cooper RD, Waterson DGE, Beebe NW.Field evaluation of repellent formulations containingdeet and picaridin against mosquitoes in NorthernTerritory, Australia. J Med Entomol. 2004;41(3):414-417.

18. Pretorius A-M, Jensenius M, Clarke F, Ringertz SH.Repellent efficacy of deet and KBR 3023 againstAmblyomma hebraeum (Acari: Ixodidae). J MedEntomol. 2003;40(2):245-248.

19. Klun JA, Khrimian A, Margaryan A, Kramer M,Debboun M. Synthesis and repellent efficacy of anew Chiral Piperidine analog: comparison with deetand BayRepel activity in human-volunteer laboratoryassays against Aedes aegypti and Anophelesstephensi. J Med Entomol. 2003;40(3):293-299.

20. McGovern TP, Schreck CE, Jackson J. Mosquitorepellents: alicyclic amides as repellents for Aedesaegypti and Anopheles quadrimaculatus. Mosq News.1978;38:346-349.


21. Carroll JF, Solberg VB, Debboun M, Klun JA,Kramer M. Comparative activity of deet and AI3-37220 repellents against the ticks Ixodes scapularisand Amblyomma americanum (Acari: Ixodidae) inlaboratory bioassays. J Med Entomol. 2004;41(2):249-254.

22. Debboun M, Strickman D, Glass JA, et al. Laboratoryevaluation of AI3-37220, AI3-35765, CIC-4, and deetrepellents against three species of mosquitoes. J AmMosq Control Assoc. 1999;15(3):342-347.

23. Debboun M, Strickman D, Solberg VB, et al. Fieldevaluation of deet and a piperidine repellent againstAedes communis (Diptera: Culicidae) and Simuliumvenustum (Diptera: Simuliidae) in the Adirondackmountains of New York. J Med Entomol. 2000;37(6):919-923.

24. Frances SP, Cooper RD, Popat S, Beebe NW. Fieldevaluation of repellents containing deet and AI3-37220 against Anopheles koliensis in Papua NewGuinea. J Am Mosq Control Assoc. 2001;17(1):42-44.

25. Frances SP, Cooper RD, Sweeney AW. Laboratoryand field evaluation of the repellents deet, CIC-4, andAI3-37220 against Anopheles farauti (Diptera:Culicidae) in Australia. J Med Entomol. 1998;35(5):690-693.

26. Frances SP, Cooper RD, Sweeney AW, Popat S.Field evaluation of the repellents deet, CIC-4, andAI3-37220 against Anopheles in Lae, Papua NewGuinea. J Am Mosq Control Assoc. 1999;15(3):339-341.

27. Solberg VB, Klein TA, McPherson KR, BradfordBA, Burge JR, Wirtz RA. Field evaluation of deetand a piperidine repellent (AI3-37220) againstAmblyomma americanum (Acari: Ixodidae). J MedEntomol. 1995;32(6):870-875.

28. Robert LL, Coleman RE, Lapointe DA, Martin PJ,Kelly R, Edman JD. Laboratory and field evaluationof five repellents against the black flies Prosimuliummixtum and P. fuscum (Diptera: Simuliidae). J MedEntomol. 1992;29(2):267-272.

29. Walker TW, Robert LL, Copeland RA, et al. Fieldevaluation of arthropod repellents, deet and apiperidine compound, AI3-37220, against Anophelesfunestus and Anopheles arabiensis in western Kenya.J Am Mosq Control Assoc. 1996;12(2 PART 1):172-176.

30. Klun JA, Schmidt WF, Debboun M. Stereochemicaleffects in an insect repellent. J Med Entomol. 2001;38(6):809-812.

31. Carroll JF, Klun JA, Debboun M. Repellency of deetand SS220 applied to skin involves olfactory sensingby two species of ticks. Med Vet Entomol. 2005;19(1):101-106.

32. Klun JA, Khrimian A, Debboun M. Repellent anddeterrent effects of SS220, picaridin, and deetsuppress human blood feeding by Aedes aegypti,Anopheles stephensi, and Phlebotomus papatasi. JMed Entomol. 2006;43(1):34-39.

Chemical Defense Against Blood-Feeding Arthropods by Disruption of Biting Behavior

AUTHORS

COL Debboun is the Chief, Medical Zoology Branch at the Department of Preventive Health Services, Academy ofHealth Sciences, US Army Medical Department Center & School, Fort Sam Houston, Texas.

Dr. Klun is a Research Entomologist at the Invasive Insect Biocontrol and Behavior Laboratory, United StatesDepartment of Agriculture, ARS Beltsville Agricultural Research Center, Beltsville, Maryland.


The Deployed Warfighter ProtectionResearch Program: Finding NewMethods to Vanquish Old Foes

CAPT Stanton E. Cope, MSC, USNCOL (Ret) Daniel A. Strickman, MS, USA

Graham B. White, PhD

*Detailed information on the DWFP can be found athttp://www.afpmb.org/dwfpresearch.htm.

INTRODUCTION

The Deployed Warfighter Protection research program(DWFP) is an initiative to develop and validate novelmethods to protect United States military deployedabroad from threats posed by disease-carrying insects.1

Vector-borne diseases such as malaria, dengue,leishmaniasis, and chikungunya are among the mostimportant health risks facing deployed troops. Thereare no vaccines for many diseases transmitted bybiting insects, so methods in insect management andcontrol, as well as personal protection, are the primarytools available to protect troops.2-5

During and following World War II, scientists fromthe US Department of Agriculture (USDA) wereregularly funded by the Department of Defense (DoD)to develop new methods and materials for controllingbiting insects, particularly those that transmit diseasesto humans. This highly successful collaborationproduced tools that are still part of our insect-controlarsenal today. Examples include:

Deet (N,N-diethyl-3-methyl-benzamide), theprimary ingredient in the majority of insectrepellents available today.

Ultra low volume application of insecticides, amethodology that distributes a limited amount ofchemical per acre by optimizing the dispersion andconcentration of size-limited droplets, now thestandard method used by spray trucks deployed toprotect neighborhoods against mosquitoes.

Permethrin-impregnated fabrics for personalprotection against the bites of ticks, mosquitoes,and other blood-feeding flying insects. Permethrinis a synthetic pyrethroid insect repellent that isused to treat uniforms, bed nets, tentage, and otherfabrics.

On a global basis, many diseases transmitted byinsects are increasing and spreading (eg, chikungunya,dengue, West Nile fever) or remain widespread andpreva lent (eg , ma lar ia , l e i shmaniases ,trypanosomiases) despite variable vector controlefforts. This situation is demonstrated in Table 1. Also,increasing numbers of species of medically importantinsects are developing resistance to insecticidescommonly used today. For strategic reasons, therefore,there is a critical need in the DoD for the types ofproducts USDA is uniquely able to provide. TheDWFP is designed to not only encourage the rapiddevelopment of such products, but also to improve thecapability of USDA to provide long-term, innovativesupport to military preventive medicine. In short, it isthe intent of the DoD, through the DWFP, to providefunding to the USDA Agricultural Research Service(ARS) to reinvigorate this mutually beneficial workingrelationship between DoD and USDA, particularly asit pertains to DWFP, as defined in 2 writtenagreements.7,8

ADMINISTRATION AND AREAS OF EMPHASISOF THE PROGRAM

The DWFP is administered by the Research LiaisonOfficer of the Armed Forces Pest Management Board.The program, which was started in Fiscal Year 04, isfunded at $5 million per year. It consists of anoncompetitive funding process for USDA ARS-basedresearch, and a competitive grants process open tonon-USDA ARS scientists. Up to $3 million per yearis given to USDA ARS, specifically to NationalProgram 104, dealing with Veterinary, Urban, andMedical Entomology. The funds are then distributed tovarious laboratories within the USDA system asdescribed below.

Up to $1.4 million is awarded each year in newcompetitive grants. The amount available for new


starts each year depends on how many projects arecarried over from previous years. Grants are awardedfor up to $250,000 per year, for up to 3 years. The callfor preproposals generally goes out around September.These are then reviewed by a DWFP TechnicalCommittee, consisting of 8 to 10 members, civilianand military, representing the Army, Navy, and AirForce. Based on preproposal reviews, investigatorsmay be asked to submit a full proposal. In November,the DWFP Committee convenes for a 2-day review ofthe USDA research and to determine which newcompetitive grants will be awarded. Final competitiveaward winners are usually notified in December.

The DWFP research portfolio is concentrated in 3specific areas: novel insecticide chemistries/formulations, application technology, and personalprotective systems. The first area includes discovery ofnew active ingredients, tests of existing insecticides onpests and vectors of public health importance,especially mosquitoes and sand flies, andreformulation of existing insecticides to improveefficacy or delivery.

INVOLVEMENT OF THE US DEPARTMENT OFAGRICULTURE

The USDA ARS has been a partner in DWFP since2004, but cooperation between the nation’sagricultural research and the military goes back manydecades. World War II was a unique moment in thisrelationship. American forces were faced with theusual disease challenges of warfare, but, for the firsttime, scientific understanding and industrial capacitycombined to offer hope of preventing those diseasescaused by vector-borne pathogens. The USDA Bureauof Entomology and Plant Quarantine laboratory inOrlando9 targeted the flea vectors of plague, the lousevectors of typhus, the chigger vectors of scrub typhus,mosquitoes including vectors of malaria and yellowfever,10 as well as bedbugs, cockroaches, flies, andticks.11 In just a few years, the laboratory refined theuses of DDT* as a control agent for public health pestsand of repellent chemicals (ethyl hexanediol, dimethylphthalate, dimethyl carbate, indalone, and benzylbenzoate) as topical and clothing repellents. Workersat the Beltsville Center invented the insecticidal

*1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane or Dichloro-diphenyl-trichloroethane

Vectors DiseasesIncidence,Prevalence

Mosquitoes

Malaria Warm regions—deaths in excess ofone million per year

Lymphatic filariasis Warm regions—infections in excessof 200 million

Arboviruses (chikungunya, dengue,Japanese encephalitis, Rift Valley fever,West Nile virus, yellow fever, etc)

Spreading—epidemics increasing

Flies and roaches Dysentery Global and repetitive

Sand flies LeishmaniasesFocal—approximately 6 million

infections a year

Fleas Plague Widespread—occasional outbreaks

Blackflies Onchocerciasis (River Blindness)Africa and Americas: focal—less

than 10 million cases

Tsetse African trypanosomiases (Sleeping Sickness)Africa: focal—less than 5 million

cases

Reduviid bugs Chagas diseaseAmericas: 24 million cases across

15 countries

Ticks and mites Borrelioses, ehrlichias etc Widespread

Table 1. Major Global Vector-borne Diseases6

Snails SchistosomiasisWarm regions—Approximately 200million cases

The Deployed Warfighter Protection Research Program:Finding New Methods to Vanquish Old Foes



aerosol bomb12 (precursor of all spray cans) formilitary use during WWII, and collaborated with theOrlando Lab to invent the repellent deet13 in 1947.

The USDA continued to collaborate with the militarythrough the 1970s and 1980s, most notably workingout the means for permethrin treatment of militaryuniforms.14-16 Concentration on military problemsslowed, eventually reduced to the development ofrepellent active ingredients and improved trappingsystems. The DWFP effort brought greater focus in 3ways. First, it provided significant funds ($3 millionper year) to the USDA ARS for research. Second, itdefined the subject areas of most interest to themilitary, namely new toxicants for public health pests,new application equipment for pesticides, and newpersonal protection system. Finally, the DWFPestablished mechanisms of communication betweenthe military and the USDA ARS that have kept bothsides engaged in the conversation on the direction ofresearch required to produce products for theprotection of military personnel from arthropods thattransmit pathogens.

During the last 3 years we have conceived andexecuted the concept of a “virtual laboratory” thattakes advantage of the core strengths of the USDAARS at each of the laboratories to establish a smoothflow for development of new vector control products.Chemical discovery proceeds from several strategiesthat are, for the most part, based on basic sciencerather than bulk screening. Promising candidatesemerge from bioassays, leading to morecomprehensive evaluation against target insects. Oncewe have what we think is a useful chemical, weconsider how best to use it against target insects in anintegrated pest and disease management program.With those goals in mind, we have in the pastapproached individual private companies in order toform a partnership for further development. In thatcase, it is up to the company to formulate the activeingredient. Recently, we have been performingresearch on formulation, reasoning that a preparationcloser to product status may be more attractive forindustrial development. We are also working onregulatory issues by funding a position on public

health pesticides with IR-4*, the USDA-funded entitythat supports registration of pesticides for use onspecialty crops.17

Some USDA ARS laboratories and investigators havehad only a temporary involvement with DWFP,depending mainly on whether the core agriculturalmission of their unit effectively synergized the militarymission of the funds. Currently, there are 5laboratories that receive DWFP funding. Thefollowing sections discuss some of the work underwayin those laboratories.

Invasive Insect Biocontrol and BehaviorLaboratory

The Invasive Insect Biocontrol and BehaviorLaboratory in Beltsville, Maryland, is the laboratorythat first patented deet13 the dominant active ingredientin American insect repellents. It continues to be well-equipped to perform any level of synthetic andanalytical chemistry, an obvious advantage for alaboratory attempting to discover new toxicants andrepellents. Chauhan and colleagues18 have beeninvolved in the discovery of promising new repellentactive ingredients, mosquito larvicides, and excitingnew insecticidal chemistries. He takes advantage of asmall Aedes aegypti colony on site and performssimple, screening bioassays to guide his work. Anotherresearch team is at the cutting edge of research on howmosquitoes detect hosts.19 Using molecular biologyand electrophysiology, they will develop tools thatdissect biting behavior into its component,physiological parts. Combined with the syntheticchemistry of the laboratory, this work will providevery precise pathways for discovering entirely newbehavior-altering chemicals. Potential products couldbe chemicals that selectively repel infectedmosquitoes, chemicals that induce mosquitoes to bitenonhuman hosts, and powerful attractants that could becombined with toxicants.

Mosquito and Fly Research Unit

Scientists at the Mosquito and Fly Research Unit(MFRU) in Gainesville, Florida, are experts on manyaspects of the biology and control of mosquitoes andflies. Their work includes the following:

*Interregional Research Project No 4 (IR-4), the Minor Crop Pest Management Program, is the principal public effort supporting theregistration of crop protection products and biological pest control agents for approximately $40 billion minor crop industry.Source: USDA Cooperative State Research, Education, and Extension Service, http://www.csrees.usda.gov/nea/pest/in_focus/ipm_if_minor.html


Toxicant discovery by Pridgeon et al20 includestests of registered toxicants that have not yet beenapplied for public health pests. They also workwith industry to explore the effectiveness of newcompounds that have not been used asinsecticides. Promising chemicals have also beenextracted from native plants.

Pridgeon and associates21 have invented anentirely new class of “molecular pesticides” thatpromise to combine great safety, flexibility, andspecificity.22,23

Bernier and colleagues have extended fundamentalwork to the production of inhibitors formosquitoes (patent pending) and powerfulattractants for flies24 and mosquitoes.25

Collaborators at the University of Florida are usingcomputational chemistry (QSAR/QSPR*) toreanalyze pesticide bioassay data generated over50 years at the Orlando and Gainesvillelaboratories, resulting in synthesis of repellentswith 3-fold longer repellency than deet.26

Researchers Cooperband and Allen27 have alsoexplored the effects of sublethal dosages ofpesticides on mosquito behavior using quantitativeinterpretation of videos, extending our knowledgeof how best to apply residual insecticides.

Research is underway on fly control, includingtrapping and toxicants, at field sites in the UnitedStates and middle eastern locations.

The Center for Medical, Agricultural, andVeterinary Entomology, which includes theMFRU, has been very active in developing fieldtests sites, including Thailand; Kenya; CampBlanding, Florida; and the Coachella Valley,California. The MFRU works closely with theNavy Entomology Center of Excellence at the USNaval Air Station, Jacksonville, Florida, especiallyfor field testing and evaluation of applicationequipment.

Biological Control of Pests Research Unit

At the Biological Control of Pests Research Unit(BCPRU) in Stoneville, Mississippi, Lyn and Streett28

collaborate with scientists at the MFRU and industryto develop formulations of public health pesticides.Also, the BCPRU has facilities for pilot production ofbiopesticides.

Natural Products Utilization Research Unit

The Natural Products Utilization Research Unit inOxford, Mississippi, has a history of working inpartnership with the University of Mississippi Schoolof Pharmacy on the discovery of natural sources ofbioactive compounds. The unit goes beyond simpleextracts to complex analysis of families of chemicalsand optimization through synthesis of series ofcompounds. Thanks to DWFP funding, USDA wasable to leverage the effort by transferring funds to theUniversity of Mississippi for insecticide development.Cantrell and colleagues29,30 have already been involvedin discovery and patent of repellents and toxicants.The products of their research will be screened on siteusing a new and very simple bioassay developed byBecnel and Pridgeon31 at the MFRU. Promisingcandidates will be evaluated in more detail by theMFRU.

Areawide Pest Management Research Unit

Hoffmann and associates32,33 at the Areawide PestManagement Research Unit (APMRU) in CollegeStation, Texas, have worked closely with the MFRUand the Navy Entomology Center of Excellence tosystematically evaluate the droplet spectra of a widerange of application equipment. The data have alreadyinformed the military on the best equipment for itspurposes. Also, Nachman’s34 completed work onneuropeptides of public health pests, includingmosquitoes, ticks, and flies, has established an entirelynew potential mechanism for insecticidal mode ofaction.

COMPETITIVE AWARD HIGHLIGHTS

Publicly posted on the federal government’s website†

announcing grant availability, DWFP requests forpreproposals have yielded an average of 38submissions annually, from academics, militaryentomologists, industry, and others around the world.More than one-third of these have been invited toprepare full proposals, from which 34 projects, shownin Table 2, have been selected for grant funding duringthe first 5 years of the program. The range of topicsand the quality of many proposals have beenimpressive. Indeed, many of the intended productscould find wider applications for public health andveterinary pest control. So far, the smallest grant valuewas $22,552 over 2 years, while some grants have

*Quantitative structure-activity relationship/quantitativestructure-property relationship † http://www.grants.gov/




Award Recipient Purpose Org* Highlights

2004 (n=8)CDR Claborn (Dr Walker) Sprayer diesel conversion M 2 prototypes & NSN†

LTC Coleman Sand Fly control--Iraq M Improved field operationsLCDR Hoffman Mosquito control with UAV‡ M Passed to USAFProf Phil Koehler Filth & Biting Fly control A 1 NSN† & 2 deployed citationsDr Bob Peterson Comparative risk analyses A Publications & public appreciationDr Steve Presley Hollow fiber impregnated fabric A Novel technologyDr Bill Reifenrath Repellent synergy D CancelledDr Ed Rowton Sand Fly control--laboratory M Essential collaborations

2005 (n=7)Prof Chas Apperson Dengue vector ovitrap A Duty under instruction studentProf Lane Foil Targeted sand fly control A WRAIR§ collaborationLT Haagsma Mosquito control with UAV‡ M Passed to USDA ARS APMRUDr Que Lan Novel mosquito insect growth regulator A Product licensedDr Mike Scharf Low molecular weight insecticides A Industry supportLT Stancil (LCDR Florin) Dengue vector larval control M EPA¶ registration in preparationProf Alon Warburg Sand Fly control military camps A WRAIR§ collaboration

2006 (n=6)Bruce Dorendorf Diesel backpack D NECE** collaborationBruce Dorendorf Ultra low volume nozzle D NECE** collaborationDave Malone New ultra low volume adulticide etofenprox D EPA¶ registration in progressDr Phil Kaufman Novel compounds A Duty under instruction studentDr Bob Peterson Comparative risk analyses A Strategic appreciationDr Gaby Zollner Novel vapor repellent M Delayed

2007 (n=3)Dr Ed Rowton Sand Fly control—WRAIR§ laboratory M Essential collaborationsMAJ Richardson Sand Fly insectary, USAMRU-K†† M Pioneering serviceDr Dolan & Dr McAllister Natural product pesticides G CDC-NCZVED‡‡ collaborations

2008 (n=10)Bruce Dorendorf Ultra low volume backpack diesel system DProf Lane Foil Sand Fly larval control AMAJ Stephen Frances Australia field repellent fabrics MPhilipp Kirsch Adulticides targeting Sand Flies DProf Phil Koehler Military protections vs Filth Flies ARichard Poche Host-target insecticides vs Sand Flies DLT Richardson Novel tools & strategies vs Ae.aegypti MProf Masoud Salyani Spray methods vs Sand Flies AProf Alon Warburg Phlebotomine control ADr Mike Willis Formulate UW4015 larvicide D

Table 2. Deployed Warfighter Protection Research Program Competitive Project Grants

*Type of organization:A – Academia (n=14) D – Industry (n=8)M – Military (n=11) G – Other government (n=1)

†National Stock Number‡Unmanned aerial vehicle§Walter Reed Army Institute of Research¶US Environmental Protection Agency**Navy Entomology Center of Excellence††US Army Medical Research Unit, Kenya‡‡US Centers for Disease Control and Prevention–National Center for Zoonotic, Vector-Borne, and Enteric Diseases


exceeded $200,000 per year for 3 years. Awardees areencouraged to seek patents and find licensees for theirproducts, several of which are already nearingcommercialization.

For example, in 2005 a grant was awarded toADAPCO (Sanford, Florida) to develop etofenprox35

for use as mosquito ultra low volume (ULV)adulticide. This chemical, a nonester pyrethroidmanufactured by the Mitsui Group in Japan andlicensed to Central Life Sciences (Schaumburg,Illinois) for US registration for public healthapplications, is far less toxic to humans, animals, andbirds than most other insecticides currently used formosquito control.36 It is expected to receive EPAapproval for marketing this year.

Although the DWFP program prioritizes the discoveryand development of agents for use against blood-feeding adult mosquitoes and biting flies that wouldafflict deployed military personnel, some researchgrants have been awarded for development ofchemicals with new modes of action against mosquitodevelopmental stages in water. At the University ofWisconsin, Madison, Lan and colleagues37-41 had theidea to block sterol carrier proteins that aremetabolically essential for the nutrition and growth ofmosquito larvae. After screening tens of thousands ofcandidate compounds, they discovered several with thepower to block mosquito sterols, effectively serving asgrowth inhibitors. The most appropriate compound hasbeen licensed by a commercial company where it isbeing formulated for applied use. Both phases of thework have been supported by DWFP grants.

Among DWFP grants awarded to scientificallyqualified military officers, the first was for adapting anunmanned aerial vehicle, shown in Figure 1, to carryapplication equipment for delivery of larvicidalgranules or ULV adulticide. This project originatedwith the Disease Vector Ecology and Control Center(now the Navy Entomology Center of Excellence) atthe Jacksonville Naval Air Station, where capabilitieswere demonstrated, then adopted by the USAF AerialSpray Unit* at Youngstown, Ohio. To further developthis application technology with an unmanned aerialvehicle platform made in the United States, the projecthas been transferred to the Application TechnologyLaboratory of the USDA ARS at the APMRU. Thisrelay of progressive research and development steps

has been facilitated by DWFP funds and objectives tomeet one of the strategic DoD goals of fieldingunmanned vehicles.

Also by collaboration with the Navy EntomologyCenter of Excellence, a series of DWFP grants haveenabled Dorendorf Advanced Technologies, Inc(Winnebago, Minnesota) to design and build newsprayers using military fuels instead of gasoline. Thefirst backpack system, shown in Figure 2, operatesalmost silently with compressed air from cylinderscharged by a diesel-fuelled compressor which alsodrives a truck-mounted ULV sprayer, theTerminator™. In addition to the strategic advantagesof silent spraying, a unique ULV nozzle is beingcreated for the backpack system. Altogether, this

Figure 1. Yamaha RMax unmanned aerial vehicle fittedwith ULV spray nozzles (top) and with twin hopper(bottom) for application of granular larvicide to controlmosquitoes.

*See related article on page 54.




purpose-built, diesel-fuelled sprayequipment will allow troops to bedeployed with battlefield-readyspray equipment for vectorcontrol.

From diverse proposals for betterinsect repellency of fabrics toprotect military personnel, oneDWFP grant was awarded toresearchers at the Institute ofEnvironmental and Human Health,Texas Tech University, Lubbock,Texas. That ingenious projectdeveloped a new type ofpermethrin-impregnated hollowfiber capable of being integratedwith many textiles. This durablemicrocapillary can serve as aconvenient carrier fiber for weaving the repellent andinsecticidal powers of permethrin into any fabrics usedfor making clothes, curtains, tents, and other protectivelayers.*

Two DWFP projects have employed pyriproxyfen, themost powerful insect growth regulator (IGR), againstdengue vector mosquitoes. In the Peruvian Amazoncommunity at Iquitos, Stancil42 (Naval MedicalResearch Center Detachment, Peru)received a grant to optimizestrategies for preventing the breedingof Aedes aegypti mosquitoes incontainers of water. The project ranfor 3 years , and involvedcollaboration with Peruvian scientistsand researchers from the Universityof California and RothamstedResearch, United Kingdom. Inaddition to simply stopping thebreeding of mosquitoes in treatedhabitats, effective quantities ofpyriproxyfen IGR are transferred from one containerto another by mosquito females as they go from site tosite laying their eggs, thus impacting more habitatsthan were treated directly. Mosquito populationsuppression across whole suburbs of the city haseffectively prevented dengue transmission without theneed to spray adulticides. Building on thatachievement, researchers at the Armed ForcesResearch Institute of Medical Sciences, Bangkok,43 in

conjunction with local militarypersonnel in Thailand, are nowevaluating several devices treatedwith pyriproxyfen IGR forprotecting military camps againstAedes aegypti and the arbovirusestransmitted by this widespreaddomestic mosquito (see Table 1).

The biggest emphasis of DWFPprojects has been to find ways tocombat Phlebotomus sand flies(Figure 3) which are problematicin many parts of the Middle East.These small hairy flies transmitLeishmania parasites that causedisfiguring sores (Figure 4) whichfester for many months and requirelong-term medication. Some forms

of the infection go to the liver and can be fatal. Morethan a thousand US personnel have contractedleishmaniasis during ongoing Operations EnduringFreedom and Iraqi Freedom.44 Unfortunately, the typesof insecticide sprays that normally control mosquitoesare generally ineffective against sand flies. To addressthis threat, DWFP grants were channeled, bycompetitive award, via the Entomology Division at theWalter Reed Army Institute of Research to facilitate

intensive field studies of sand flybehavior and control. Although aseries of research papers by Coleman,Burkett, and colleagues45-47 haveresulted, the sand fly biting problemhas not been resolved. Consequently,efforts to understand how to improvethe delivery of more effectiveinsecticidal sprays are beingreemphasized. Also, Warburg andcolleagues48 at the Kuvin Center ofthe Hadassah Medical School,Jerusalem, received a DWFP grant to

develop measures to protect outposts against sandflies. These projects have revealed that sand flies oftenemerge from the soil beneath tents and camps. In aneffort to prevent sand flies breeding in rodent burrows,the Genesis Company (Wellington, Colorado) won anaward for producing insecticidal baits that would passthrough specific rodent reservoir hosts of leishmaniasisto prevent breeding of sand fly larvae in their burrows.This approach is being developed with other feed-through treatments by Mascari et al49-51 at Louisiana

Figure 2. The first backpack ULVsprayer system developed underDWFP grants operates almost silentlywith compressed air from cylinders.

Figure 3. Phlebotomus sand fly(Photo courtesy of Ed Rowton, PhD)

*Project results unpublished to date


State University for field testing against sand flies inTurkey.

Control of filth flies and house flies is best achieved bygood sanitation, but this cannot always be ensured indeployment situations. One competitive DWFP awardenabled Koehler52 and military students in the UrbanEntomology Unit of the Department of Entomologyand Nematology at the University of Florida,Gainesville, to optimize some old countermeasures forfly control. For example, one student evaluatedpesticides for residual treatments of various types ofstring and rope on which flies like to rest. Hedetermined which combination of insecticide andstring fiber would be most effective for use againstflies in tented camps. Another student continues thisline of experimentation by devising ways to drapeloops of treated string over attractant traps to whichflies are lured and killed. These masters level graduatestudents were supported by the US Navy’s Medical

Service Corps Inservice Procurement Program.53

Another development from Koehler’s team, invisibleimidacloprid paint bait with attractant for killing fliesquickly, was the first DWFP product to receive aNational Stock Number from the Armed Forces PestManagement Board.

As the DWFP competitive grants program has grown,awardees have included entomologists at the USCenters for Disease Control, Division of Vector-Borneand Zoonotic Diseases, for development of naturalpesticides extracted from agricultural waste. Otherplant products that have insect repellent properties areunder evaluation for insecticidal potency against flies,mosquitoes, and sand flies, while Scharf and Song54,55

are exploring low molecular weight compounds thatcould serve as volatile repellents and insecticides forpotential limitation of biting insects over a wide area.

Although the public perception of pesticides can beunfavorable, the facts are that the use of pesticides canbe extremely effective against all sorts of pests anddisease vectors. In an effort to investigate thisdichotomy, one of the most original lines of inquiryfunded by DWFP competitive grants has allowedPeterson and colleagues56-61 at Montana StateUniversity, Bozeman, to undertake comparative riskanalyses of the impact of pesticides. For a series ofmodel scenarios involving vector-borne diseases suchas malaria, West Nile fever, and plague, they carefullyquantified the likely benefits of vector control bymeans of appropriate insecticide applications, versuspossible disadvantages to the health of people andenvironmental impact. One particular study by Macedoet al62 weighed the potential health benefits of vectorcontrol against the adverse consequences of likelyexposure of deployed military personnel to pesticidesused on clothing and bed nets, and sprayed around thecamp. In all cases, the risk to humans was found to beminimal compared with the health benefits of avoidingvector-borne diseases.

UPGRADING DEFENSE AGAINST DISEASESTRANSMITTED BY INSECT BITES

While many useful products from DWFP research arealready on the way towards production and supply forthe public as well as deployed troops, the examplesdescribed above are far from sufficient to cover all ourneeds. Apart from combating mosquitoes and thevarious types of flies that transmit debilitating

Figure 4. Examples of dermal leishmaniasis contractedin Iraq during Operation Iraqi Freedom. Note in the topphoto that the area of the arm covered by the shirtsleeve is free of bites, demonstrating the value of simplemeasures in the prevention of insect bites.(Photos courtesy of COL Russell Coleman, MS, USA)




infections such as malaria, leishmaniasis, dengue, andother arboviruses, there are many other noxious typesof biting insects (bedbugs, fleas, lice, etc) and otherarthropods (ticks, mites, scorpions, etc) that merit ourconcern. With nearly 5 years of progress in the DWFPprogram, however, our focus remains on the mostdangerous flying vectors, particularly certain speciesof mosquitoes and sand flies. That focus is necessaryuntil we have greatly improved methods and materialsto protect our forces deployed to forward situations inall regions of the world from the threats ofinconspicuous insect foes. This will allow those forcesto more effectively deal with the challenges presentedby the more obvious human enemies.

REFERENCES

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2. Coates JB, ed-in-chief. Communicable diseases,malaria. Washington, DC: Office of The SurgeonGeneral, US Dept of the Army; 1963. Hoff EC, ed.Preventive Medicine in World War II; vol 6.

3. Dickens T. Vector control as a force multiplier.Defense 90. September/October 1990:26-35.

4. Technical Guide 36, Personal Protective TechniquesAgainst Insects and Other Arthropods of MilitaryImportance. Washington, DC: US Armed Forces PestManagement Board. 2003. Available at: http://www.afpmb.org/coweb/guidance_targets/ppms/TG36/TG36.htm.

5. Debboun M, Robert L, O’Brien L, Johnson R, BertéS. Vector control and pest management. Army MedDept J. 2006;24:31-39.

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7. Master Memorandum of Understanding BetweenUnited States Department of Defense and UnitedStates Department of Agriculture Relative toCooperation with Respect to Food, Agriculture, PestManagement, Nutrition, Related Homeland SecurityRequirements, and other Research of Mutual Interest.Washington, DC: US Dept of Agriculture & US Deptof Defense; March 14, 2003. Available at: http://www.afpmb.org/pubs/misc/mastr_usda.pdf.

8. Supplement to Master Memorandum ofUnderstanding Between US Department of Defenseand US Department of Agriculture, Relative toCooperation with Respect to Food, Agriculture, PestManagement, Nutrition, Related Homeland SecurityRequirements, and other Research of Mutual Interest.Washington, DC: US Dept of Agriculture & US Deptof Defense; February 5, 2004. Available at: http://www.afpmb.org/pubs/misc/MMOU-Supplement.pdf.

9. Knipling EF. Insect control investigations of theOrlando, Fla, laboratory during World War II.Smithson Rep for 1948. Washington, DC:Smithsonian Institution; 1949:331-348. SmithsonianPublication 3968.

10. King WV. Chemicals evaluated as insecticides andrepellents at Orlando, FLA; Agricultural HandbookNo. 69. Washington, DC: Agricultural ResearchService, US Dept of Agriculture; 1954.

11. Materials Evaluated as Insecticides, Repellents, andChemosterilants at Orlando and Gainesville, FLA,1952-1964. Agricultural Handbook No. 340.Washington, DC. Agricultural Research Service, USDept of Agriculture; 1967.

12. Sullivan WN. The coupling of science andtechnology in the early development of the WorldWar II aerosol bomb. Mil Med. 1971;136(2):157-158.

13. McCabe ET, Barthel WF, Gertler SI, Hall SA. Insectrepellents, III. N, N-diethylamides. J Org Chem.1954;19:493–498.

14. Schreck CE, Posey K, Smith D. Durability ofpermethrin as a potential clothing treatment to protectagainst blood-feeding arthropods. J Econ Entomol.1978;71:397-400.

15. Schreck CE, Smith N, McGovern TP. Repellency ofselected compounds against two species of bitingmidges (Diptera: Ceratopogonidae: Culicoides). JMed Entomol. 1979;16:524-527.

16. Schreck CE, Snoddy EL, Spielman A. Pressurizedsprays of permethrin or DEET on military clothingfor personal protection against Ixodes dammini(Acari: Ixodidae). J Med Entomol. 1986;23:396-399.

17. IR-4 Project website. Available at: http://www.ir4.rutgers.edu/index.html.

18. Chauhan KR, Klun JA, Debboun M, Kramer M.Feeding deterrent effects of catnip oil componentscompared with two synthetic amides against Aedesaegypti. J Med Entomol. 2005;42(4):643-646.


19. Nichols Z, Vogt RG. The SNMP/CD36 gene familyin Diptera, Hymenoptera and Coleoptera: Drosophilamelanogaster, D. pseudoobscura, Anophelesgambiae, Aedes aegypti, Apis mellifera, andTribolium castaneum. Insect Biochem Mol Biol.2008;38:398-415.

20. Pridgeon JW, Pereira RM, Becnel JJ, Allan SA, ClarkGG, Linthicum KJ. Susceptibility of Aedes aegypti,Culex quinquefasciatus Say, and Anophelesquadrimaculatus Say to 19 pesticides with differentmodes of action. J Med Entomol. 2008;45(1):82-87.

21. Pridgeon JW, Becnel JJ, Strickman DA, inventors.New method for developing molecular pesticides.Patent application serial number 11/716,499 Docket#0122.06, March 9, 2007. Information available at:h t tp : / / www.a r s . u sd a .go v / r e sea r c h /p a te n t s /patents.htm?serialnum=11716499.

22. Zhao L, Pridgeon JW, Becnel JJ, Clark GG,Linthicum KJ. Cytochrome c gene and proteinexpression: developmental regulation, environmentalresponse, and pesticide sensitivity in Aedes aegypti. JMed Entomol. 2008;45:401-408.

23. Pridgeon JW, Zhao L, Becnel JJ, Strickman DA,Clark GG, Linthicum KJ. Topically applied AaeIAP1double-stranded RNA kills female adults of Aedesaegypti. J Med Entomol. 2008;45:414-420.

24. Quinn BP, Bernier UR, Geden CJ, Hogsette JA,Carlson DA. Analysis of extracted and volatilecomponents in blackstrap molasses feed as candidatehousefly attractants. J Chromatograph A. 2007;1139(2):279-284.

25. Katritzky AR, Wang Z, Slavov S, Tsikolia M,Dobchev D, Akhmedov NG, Hall CD, Bernier UR,Clark GG, Linthicum KJ. Synthesis and bioassay ofimproved mosquito repellents predicted fromchemical structure. Proc Natl Acad Sci USA.2008;105(21):7359-7364.

26. Bernier UR, Allan SA, Quinn BP, Kline DL, BarnardDR, Clark GG. Volatile compounds from theintegument of White Leghorn Chickens (Gallusgallus domesticus L.): candidate attractants ofornithophilic mosquito species. J Sep Sci.2008;31:1092-1099.

27. Cooperband MF, Allan SA. Behavioral definitions,“excito-repellency,” and is meaning with respect tomosquito contact with treated surfaces. Abstract 242of the 74th Annual Meeting, American MosquitoControl Association, Sparks, Nevada. 2-6 March2008. Mount Laurel, NJ: American Mosquito ControlAssociation; 2008:44. Available (registrationrequired) at: http://www.afpmb.org/pubs/dwfp/meetings/amca2008/224-cooperband.pdf.

28. Lyn ME, Streett D, Becnel J. New mosquitobiolarvicide formulation for improved residualactivity. Abstract 242 of the 74th Annual Meeting,American Mosquito Control Association, Sparks,Nevada. 2-6 March 2008. Mount Laurel, NJ:American Mosquito Control Association; 2008:47.

29. Cantrell CL, Klun JA, Bryson CT, Kobaisy M, DukeSO. Isolation and identification of mosquito bitedeterrent terpenoids from leaves of American(Callicarpa americana) and Japanese (Callicarpajaponica) beautyberry. J Agric Food Chem.2005;53:5948-5953.

30. Pridgeon JW, Meepagala KM, Becnel JJ, Clark GG,Pereira RM, Linthicum KJ. Structure-activityrelationships of 33 piperidines as toxicants againstfemale adults of Aedes aegypti (Diptera: Culicidae). JMed Entomol. 2007;44(2):263-269.

31. Becnel JJ, Pridgeon JW. A high throughput screeningmethod to identify potential pesticides for mosquitocontrol. J Med Entomol. In press.

32. Hoffmann WC, Walker TW, Smith VL, Martin DE,Fritz BK. Droplet-size characterization of handheldatomization equipment typically used in vectorcontrol. J Am Mosq Control Assoc. 2007;23:315-320.

33. Hoffmann WC, Walker TW, Martin DE, Barber JA,Gwinn T, Smith VL, Szumlas D, Lan Y, Fritz BK.Characterization of truck-mounted atomizationequipment typically used in vector control. J AmMosq Control Assoc. 2007;23:321-329.

34. Nachman RJ. Invertebrate Neuropeptides VIII.Introduction. Peptides. 2008;29:149-151.

35. World Health Organization. Report of the 3rdWHOPES Working Group Meeting, 23-24 September1999; Review of: Deltamethrin 1%SC and 25%WT;Etofenprox 10%EC and 10%EW. Geneva,Switzerland: World Health Organization; 1999:Document CDS/CPE/WHOPES/99.4.

36. Croft AM, Baker D, von Bertele MJ. An evidence-based vector control strategy for militarydeployments: the British Army experience. Med Trop(Mars). 2001;61:91-98.

37. Lan Q, Wessely V. Expression of a sterol carrierprotein-x gene in the yellow fever mosquito, Aedesaegypti. Insect Mol Biol. 2004;13:519–529.

38. Blitzer EJ, Yazunova I, Lan Q. Functional analysis ofAeSCP-2 using gene expression knockdown in theyellow fever mosquito, Aedes aegypti. Insect MolBiol. 2005;14:301-307.




39. Kim MS, Wessely V, Lan Q. Identification ofmosquito sterol carrier protein-2 inhibitors. J LipidRes. 2005;46:650-657.

40. Vyazunova I, Wessley V, Kim M, Lan Q.Identification of two sterol carrier protein-2 likegenes in the yellow fever mosquito, Aedes aegypti.Insect Mol Biol. 2007;16:305–314.

41. Larson RT, Wessely V, Jiang Z, Lan Q. Larvicidalactivity of sterol carrier protein-2 inhibitor in fourspecies of mosquitoes. J Med Entomol. 2008;45(3):439-444.

42. Sihuincha M, Zamora-Perea E, Orellana-Rios W,Stancil JD, Lopez-Sifuentes V, Vidal-Oré C, DevineGJ. Potential use of pyriproxyfen for control of Aedesaegypti (Diptera: Culicidae) in Iquitos, Peru. J MedEntomol. 2005;42(4):620-630.

43. Armed Forces Research Institute of Medical Scienceswebsite. Available at: http://www.afrims.org.Accessed May 1, 2008.

44. Aronson NE. Leishmaniasis in relation to service inIraq/Afghanistan, U. S. armed forces, 2001-2006.Med Surveill Mon Rep. 2007;14(1):2-5.

45. Coleman RE, Burkett DA, Putnam JL, et al. Impactof phlebotomine sand flies on US military operationsat Tallil Air Base, Iraq: 1. background, militarysituation, and development of a leishmaniasis controlprogram. J Med Entomol. 2006;43(4):647-662.

46. Coleman RE, Burkett DA, Sherwood V, et al. Impactof phlebotomine sand flies on US military operationsat Tallil Air Base, Iraq: 2. temporal and geographicdistribution of sand flies. J Med Entomol. 2007;44(1):29-41.

47. Burkett DA, Knight R, Dennett JA, Sherwood V,Rowton E, Coleman RE. Impact of phlebotominesand flies on US military operations at Tallil AirBase, Iraq: 3. evaluation of surveillance devices forthe collection of adult sand flies. J Med Entomol.2007;44(2):381-384.

48. Jaffe CL, Baneth G, Abdeen ZA, Schlein Y, WarburgA. Leishmaniasis in Israel and the PalestinianAuthority. Trends Parasitol. 2004;20:328-332.

49. Mascari TM, Mitchell MA, Rowton ED, Foil LD.Evaluation of novaluron as a feed-through insecticidefor control of immature sand flies (Diptera:Psychodidae). J Med Entomol. 2007;44(4):714-717.

50. Mascari TM, Mitchell MA, Rowton ED, Foil LD.Laboratory evaluation of diflubenzuron as a feed-through for control of immature sand flies (Diptera:Psychodidae). J Med Entomol. 2007;44(2):171-174.

51. Mascari TM, Mitchell MA, Rowton ED, Foil LD.Ivermectin as a rodent feed-through insecticide forcontrol of immature sand flies (Diptera:Psychodidae). J Am Mosq Control Assoc. 2008;24(2):323-326.

52. Koehler P. DWFP fly control research. Paperpresented at: 2007 DoD Pest Management Workshop;February 12-16, 2007; Jacksonville Naval AirStation, Florida. Available at: http://www.afpmb.org/meetings/TriService2007/Presentations/Wednesday/BOQAfternoon/Koehler.ppt.

53. OPNAV Instruction 1420.1A; Enlisted to OfficerCommissioning Programs Application AdministrativeManual. Washington, DC: Office of the Chief ofNaval Operations, US Dept of the Navy; May 2,2003: chap 6.

54. Scharf ME, Nguyen SN, Song C. Evaluation ofvolatile low molecular weight insecticides usingDrosophila melanogaster as a model. Pest ManagSci. 2006;62:655-663.

55. Nguyen SN, Song C, Scharf ME. Toxicity,synergism, and neurological effects of novel volatileinsecticides in insecticide-susceptible and -resistantDrosophila strains. J Econ Entomol. 2007;100:534-544.

56. Peterson RK, Macedo PA, Davis RS. A human-healthrisk assessment for West Nile virus and insecticidesused in mosquito management. Environ HealthPerspect. 2006;114(3):366-372.

57. Davis RS, Peterson RK, Macedo PA. An ecologicalrisk assessment for insecticides used in adultmosquito management. Integr Environ AssessManag. 2007;3:373-382.

58. Antwi F, Shama LM, Peterson RKD. Riskassessments for the insect repellents DEET andpicaridin. Regul Toxicol Pharmacol. 2008;51(1):31-36.

59. Schleier JJ, Shama LM, Davis RS, Macedo PA,Peterson RKD. Equine risk assessment forinsecticides used in adult mosquito management.Hum Ecol Risk Assess. 2008;14:392-407.

60. Schleier JJ, Peterson RKD, Macedo PA, Brown DA.Environmental concentrations, fate, and riskassessment of pyrethrins and piperonyl butoxide afteraerial ultra-low-volume applications for adultmosquito management. Environ Toxicol Chem.2008;27:1063-1068.


61. Schleier JJ, Macedo PA, Davis RS, Shama LM,Peterson RKD. A two-dimensional probabilistic acutehuman-health risk assessment of insecticide exposureafter adult mosquito management. Stoch Environ ResRisk Assess. 2008; 22, doi:10.1007/s00477-008-0227-5.

62. Macedo PA, Peterson RK, Davis RS. Riskassessments for exposure of deployed militarypersonnel to insecticides and personal protectivemeasures used for disease-vector management. JToxicol Environ Health. 2007;70(20):1758-1771.


AUTHORS

CAPT Cope is the Research Liaison Officer of the Armed Forces Pest Management Board, Washington, DC.

COL (Ret) Strickman is the National Program Leader, Program 104: Veterinary, Medical, and Urban Entomology atthe US Dept of Agriculture, Agricultural Research Service, Beltsville, Maryland.

Dr White is Technical Consultant for the Deployed Warfighter Protection Research Program, based at the Mosquitoand Fly Research Unit, Center for Medical, Agricultural, and Veterinary Entomology, USDA Agricultural ResearchService, Gainesville, Florida.

COL DUNEMN JOINS THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL Kathleen N. Dunemn, AN,USA, as a member of the Editorial Review Board. COL Dunemn isChief, Department of Nursing Science, Academy of Health Sciences,AMEDD Center and School, Fort Sam Houston, Texas, and theNursing Education/Enlisted Training Consultant to the Office of TheSurgeon General.

COL Dunemn joins the board replacing COL Patricia Patrician, AN,USA. COL Patrician has been a member of the Board since October,2004. We thank COL Patrician for her dedication to the highstandards and professional quality of this publication, and her years ofservice and support to our mission.

The Editors


The Vector Surveillance Analytic System (VSAS) is aportable, field-durable, field-sustainable, real-time,arthropod-borne agent detection platform used tosupport disease surveillance operations at far forwardlocations. The VSAS was originally developed toestablish a DoD deployable methodology for denguevirus detection, but focus on system capability wasredirected to Leishmania detection and deployed inAugust 2003 to support the Leishmaniasis ControlProgram (LCP) of the 520th Theater Army MedicalLaboratory, Tallil Air Base (AB), Iraq.1 The mobilityof the VSAS allowed direct support to US ArmyPreventive Medicine and US Air Force Public HealthLeishmania surveillance operations throughout theLCP area of responsibility. Force health protectionsupport was provided at Camp Victory; BaghdadInternational Airport AB; Balad AB; and Kirkuk AB,Iraq; and Kabul, Afghanistan, from February toOctober of 2004.

The VSAS operates as a standalone field surveillanceactivity or as an extension of other deployable assets,such as the US Army Area Medical Laboratory or theAir Force Biological Augmentation Team. The fieldutility of the VSAS is clearly proven in diverseoperational applications and environmental conditions;Leishmania surveillance Southwest Asia,2 denguesurveillance at Joint Task Force Bravo, Honduras,3,4

and with the Armed Forces Research Institute ofMedical Sciences, Bangkok, Thailand.5 It has alsobeen adapted for use in the Arctic by NASA* in thedevelopment of genomics-based identificationmethodologies for the Haughton-Mars Project† onDevon Island in the Territory of Nunavut, Canada.

The VSAS addresses a requirement established by theJoint Program Executive Office (JPEO) for Chemicaland Biological Defense for the development ofdeployable identification technologies for diseaseagents of operational significance.6 The JPEO hasdesignated Leishmania and dengue virus as threatagents (Block 1, Tier 2). To address that threat, testingis underway to incrementally establish VSAStechnologies as subcomponents of the Joint BiologicalAgent Identification and Diagnostic System (JBAIDS),a JPEO/DoD accepted analytic system.

The VSAS is composed of:

1. Thermally-stable, hydrolytic enzyme resistant,freeze-dried, dual-fluorogenic, polymerase chainreaction (PCR) and reverse transcription-PCR(RT-PCR) assays and positive control template,genomic DNA and Armored-RNA® (Asuragen,Incorporated, Austin, Texas).7,8

2. Preformatted sample stabilization and processingmaterials.

3. Two-man transportable, field-durable, real-timePCR instrumentation: the Ruggedized AdvancedPathogen Identification Device (RAPID®)(Idaho Technology Incorporated [ITI], Salt LakeCity, Utah).

Assay primer and probe oligonucleotides are designedde novo, and freeze-dried PCR reagents aremanufactured by ITI.2,3 Assays are prepared using anITI proprietary formulation that is formatted tostandardized PCR and RT-PCR thermal cyclingprotocols. The ITI vector surveillance reagent kit ispreformatted with color coding to simplifypreparation. Freeze-dried assays only require hydrationand addition of sample template prior to analysis. Thethermal-stable property of the assays eliminate the

Support of Far-Forward Disease SurveillanceOperations with Deployable, Real-TimeVector-Borne Disease Agent AnalyticCapability

Col James A. Swaby, BSC, USAFJames C. McAvin

*National Aeronautics and Space Administration†Information on the research project available at:

http://www.marsonearth.org/


need for a -20°C cold chain that is typically requiredfor PCR reagents, thus vastly enhancing the mobilityof the system. It also eliminates cold storage andresupply requirements that are unacceptable under far-forward deployed conditions.

Arthropod nucleic acid extracts are prepared with acommercially available, off-the-shelf, thermally stable,preformatted, guanidinium thiocyanate based totalnucleic acid (DNA and RNA)purification kit, QIAamp ViralRNA Mini Kit (QIAGEN,27220 Turnberry Lane,Valencia, California 91355).Extract is prepared followingthe manufacturer’s spinprotocol with the exception thatthe carrier RNA step is notimplemented, thus eliminatingthe need for a 4°C cold chain.Also, centrifugation steps areadapted to the RAPID minicentrifuge, eliminating the needfor a tabletop centrifuge. Thiskit has been adopted because ofits field-worthiness and itscapability to extract totalnucleic acid in a standardized,single protocol which isapplicable to organisms harboring either RNA or DNAgenomes. Two other advantages of the kit are the lysisbuffer, “Anschlagpuffer Virus Lysis” (AVL), whichhas been shown to inactivate infectious agents,9 thusproviding an additional level of safety whenprocessing samples, and the genomic RNA template,which has been shown to remain stable in AVL atambient temperatures (25ºC to 37ºC) for days toweeks. The kit efficiently purifies nucleic acid fromdiverse matrices, to include mammalian body fluidsand tissues and arthropod homogenate.

The RAPID PCR thermocycler, is a real-time fluori-meter with a closed capillary design and 32-samplecapacity.10,11 The thermocycler is operated by a laptopcomputer with programmable PCR cycling conditions.Data management is automated. The RAPID minicentrifuge is used for sample preparation and capillaryloading. The RAPID thermocycler is thecommercialized version of the JBAIDS thermocycler.Since the technologies of these thermocyclers are

essentially identical, assays can be readily transitionedfrom one instrument to the other.

The VSAS, including several hundred assays andsample processing materials, are transported in 2hardened, waterproof cases (63 49.2 35.2 cm).The VSAS is routinely transported as personalequipment on military helicopters or fixed-wingaircraft, or transported on commercial airlines as

baggage. Ground transportationis by light vehicle or carriedmanually. The small footprint ofthe VSAS allows configurationon a truck tailgate with thesystem powered by a 110V or220V source, usually an electricgenerator, or, if necessary, the12V battery of a vehicle withthe engine running. Theefficiency of preformattedreagent and sample preparationkits, along with the closedcapillary design of the RAPID,permit sample processing andmaster mix preparation to beconducted without a biologicalcontainment hood or spatialseparation. However, in order totailor protective measures to the

surveillance requirements, appropriate operatorpersonnel protective equipment must be provided andpersonnel made aware of which vector(s) will berecovered. System configuration requires about 10minutes, and sample processing and analysis less than2 hours.

The VSAS provides deployable analytic capability forreal-time vector-borne disease risk assessment. This isparamount in affecting time-critical and focuseddisease prevention and control measures. This isespecially relevant to leishmaniasis and dengue feverbecause, in the absence of a vaccine or prophylacticdrug, the only means of protecting deployed militarypersonnel is the prevention of bites by infectedarthropods. Prevention and control of transmission ismost effectively achieved through heightenedawareness of the need for personal protectivemeasures, and by reduction in vector populations.Focused application of insecticides and elimination ofbreeding habitat in areas where the risk is greatest—

The Ruggedized Advanced PathogenIdentification Device.

Support of Far-Forward Disease Surveillance Operations with Deployable,Real-Time Vector-Borne Disease Agent Analytic Capability



where infected vectors and breeding populations arefound—are the most effective uses of vector controlresources to reduce transmission.1,2

The Armed Forces Pest Management Board (AFPMB)has approved Leishmania genus (LEIS) and visceralgenotype (LVL) PCR assays as DoD acceptedmethodologies for Leishmania vector surveillance. TheVSAS dengue RT-PCR assay (DU-JCM) wassubmitted to AFPMB in February 2008. The LEIS,

LVL, and DU-JCM assays will be submittedconcurrently to the JPEO for approval as candidatesfor clearance by the US Food and Drug Administrationon the JBAIDS. Additional assays of operationalsignificance are in development.

The VSAS is a joint US Air Force, Army, and Navyproduct developed through a Cooperative Researchand Development Agreement with ITI, the JPEOprimary contractor.

ACKNOWLEDGEMENT

The authors thank MAJ Jason Richardson, MS, USA, for his comments and suggestions in reviewing this article.

The VSAS development was funded in part by the US Air Force Protection Battle Lab, Lackland Air ForceBase, San Antonio, Texas, and the Directorate of Modernization in the Office of the Air Force Surgeon General,Falls Church, Virginia.

The Vector Surveillance Analytic System operating in the field environment in Thailandduring August 2007.


REFERENCES

1. Coleman RE, Burkett DA, Putnam JL, et al. Impactof Phlebotomine sand flies on US military operationsat Tallil Air Base, Iraq: background, militarysituation, and development of a “LeishmaniasisControl Program”. J Med Entomol. 2006;43:647-662.

2. McAvin JC, Coleman RE, Hochberg LP, et al.Detection of Leishmania parasites and visceralleishmaniasis genotype identification in sand flies byfield-deployable, real-time polymerase chainreaction. J Med Entomol. In press.

3. McAvin JC, Escamilla EM, Blow JA, et al. Rapididentification of dengue virus by RT-PCR usingfield-deployable instrumentation. Mil Med. 2005;170(12):1053-1059.

4. McAvin JC, Bowles DE, Swaby JA, et al.Identification of Aedes aegypti and its respective lifestages by real-time PCR. Mil Med. 2005;170(12):1060-1065.

5. McAvin JC, Powers MD, Blow JA, Putman JL, HuffWB, Swaby JA. Deployable, field-sustainable RT-PCR assays for rapid screening and serotypeidentification of dengue virus in mosquitoes. MilMed. 2007;172:329-334.

6. Niemeyer DM, Wilson S, et al. Enhanced laboratorycapabilities: the joint biological agent identificationand diagnostic system. Society Scope [Society ofArmed Forces Medical Laboratory Scientists serialonline]. 2003;6(3). Available at: http://www.safmls.org/Scopes/Scope%20-%202003%20Fall.pdf.

7. Pasloske BL, Walkerpeach CR, Obermoeller RD,Winkler M, DuBois DB. Armored RNA technologyfor production of ribonuclease resistant viral RNAcontrols and standards. J Clin Micro. 1998;36:3590-3594.

8. Walkerpeach CR., Winkler M, DuBois DB, PasloskeBL. Ribonuclease-resistant RNA controls (armoredRNA) for reverse transcription-PCR, branched DNA,and genotyping assays for hepatitis C virus. ClinChem. 1999;45:2079-2085.

9. Blow JA, Dohm DJ, Negley DL, Mores CN. Virusinactivation by nucleic acid extraction reagents. JVirol Meth. 2004;119:195-198.

10. Wittwer CT, Ririe KM, Andre RV, David DA,Gundry RA, Balis UJ. The lightcycler: amicrovolume multisample fluorimeter with rapidtemperature control. Bioechniques. 1997;22:176-181.

11. Wittwer CT, Herrmann MG, Moss AA, RasmussenRP. Continuous fluorescence monitoring of rapidcycle DNA amplification. Biotechniques.1997;22:130-138.

AUTHORS

Col Swaby is Chief, 59th Clinical Research TrainingDivision, 59th Medical Wing, and Principle Investigator,Vector-borne Disease Surveillance, 59th Medical Wing/SGR, Lackland Air Force Base, Texas. He is alsoAssociate Biomedical Sciences Corps Chief for MedicalEntomology, and Consultant to the USAF SurgeonGeneral for Entomology.

James McAvin is a Molecular Biologist with the 59thClinical Research Training Division, 59th MedicalWing, Lackland Air Force Base, Texas.

Support of Far-Forward Disease Surveillance Operations with Deployable,Real-Time Vector-Borne Disease Agent Analytic Capability


BACKGROUND

“What kind of war do you prepare for when youcannot prepare for them all?” Andrew Krepinevichposes the question in his analysis of the US Armybefore, during, and after a counterinsurgency inVietnam.1 The question has resurfaced as the Armyagain finds itself operating in a counterinsurgency inIraq. Has the Army as an institution learned andimplemented change based on experiences in thePhilippines during the early 20th century, or Vietnam,Lebanon, and El Salvador in the latter part of the samecentury? Are we trained and equipped to contributetoward an overarching US government strategyaddressing underlying factors of an insurgency?Although the broader questions have been debated andrecommendations published, the role of preventivemedicine (PM) in support of counterinsurgencyoperations has not.

Counterinsurgency is, by definition, “Those military,paramilitary, political, economic, psychological, andcivic actions taken by a government to defeat aninsurgency.”2 The recently published Army FieldManual 3-24: Counterinsurgency3 emphasizespolitical, social, and economic programs as morevaluable than kinetic force in addressing the root causeof an insurgency. In the absence of legitimategovernments providing for the population, insurgentsdeliver essential services such as water, electricity,

sanitation, and medical care. Hezbollah exemplifiesthis characterization in the care and services theyprovide for the Lebanese population in exchange forindividuals to fill their militia ranks. This patternreplicated itself in the streets of Baghdad, as observedby then MG Peter Chiarelli.4 He found “…anti-coalition and antigovernment religious rhetoricoriginated from those areas of Baghdad characterizedby low electrical distribution, sewage running rawthrough the streets, little to no potable waterdistribution, and no solid waste pickup.…a directcorrelation existed between the level of localinfrastructure status, unemployment figures, andattacks on US Soldiers.” MG Chiarelli studied theseunderlying factors and achieved success by focusingreconstruction and employment efforts on sewage,water, electricity, and trash removal—what he called“SWET.” Three of these 4 services make up corecompetencies of Army PM personnel. Is PM currentlybeing leveraged in Iraq, Afghanistan, and the Horn ofAfrica to contribute toward the overall strategic effort?That is debatable. Are they formally trained incounterinsurgencies and doctrinally established tomeet the demand? Not really.

APPLICATION OF CURRENT DOCTRINE

Doctrine for Level III PM detachments is driven bymultiple Department of Defense (DoD) Directives andInstructions, Army Regulations, Department of the

Level III Preventive Medicine in aCounterinsurgency Environment

MAJ Derek J. Licina, MS, USA

ABSTRACT

As the Department of Defense moves forward to secure Baghdad, military forces are being strategicallydispersed in very austere environments. These forces live and work side-by-side with their Iraqi counterparts inan effort to clear, hold, and reconstruct the city block by block, and further separate the insurgents from thegeneral population. Level II preventive medicine (PM) personnel directly support these forces and keep them inthe fight by reducing acute illness and disease and nonbattle injuries. Level III PM is performing the traditionalPM mission of reducing both acute and chronic illness while conducting Deployment OccupationalEnvironmental Health Surveillance and supporting Level II PM. However, the doctrinal basis of Level IIIallocation and priorities of core competencies have shifted. Are we meeting the need? This article attempts toanswer the question based on experience as a Level III PM detachment commander in Baghdad, and providerecommendations for change across the spectrum of the Army’s structure of doctrine, organizations, training,materiel, leadership, education, personnel, and facilities.


Army Pamphlets, and myriad Field Manuals. The mostrobust description of duties and responsibilities isfound in Field Manual 4.02-17, Preventive MedicineServices,5 which was last updated in August 2000. Ithighlights Level III support in the areas of medicalthreat analysis, health hazard assessment, disease andnonbattle injury (DNBI) surveillance, health physicssurveys, disease-vector identification, environmentalhealth assessments, and field sanitation team training,among other operational capabilities. These areas arerelevant in both permissive and nonpermissiveenvironments, though their overall priority may shift.PM services in stability, support, and civil-militaryoperations are discussed in Field Manual 4.02-17 andmore accurately describe what contributions PM canmake in a counterinsurgency.

During the 2007 surge in operations in Baghdad, the61st Medical Detachment provided Level III supportto the multinational divisions in Baghdad and centralIraq which were engulfed in a counterinsurgency. Over70,000 US, Coalition, contractor, and third countrynationals supported operations in this nefarious battlespace. Doctrinally established to support 17,000personnel, the 61st Medical Detachment in realityperformed the mission of 4 detachments. Theyprovided support in an area over 80,000 km2, including20 forward operation bases (FOBs), 70 joint securitystations (JSSs) and combat outposts (COPs), and theVictory Base Complex, which is equivalent to amidsize municipality in the United States. Doctrinestates that Level III PM is 100% mobile, however,during the counterinsurgency in Iraq, this has onlybeen true on the FOBs to which they were assigned.Moving between FOBs requires external support suchas uparmored* vehicles, helicopters, and stalwartsecurity. The criteria for this doctrinal basis ofallocation should be further explored. New criteriasuch as the number of Level II PM assets supported, ortype of conflict (counterinsurgency, peacekeeping, ordisaster response/humanitarian assistance) could beadded and weighted to determine operational needs onthe ground.

During the Operation Iraqi Freedom (OIF) 06-08rotation, the 61st Medical Detachment executed amajority of these doctrinal tasks. Prior to deployment,

a medical threat profile based on hazards in the area ofoperation was developed. Not considered during thisanalysis were diseases that could be brought intotheater by Coalition forces and contract partners whomay not require stringent predeployment healthscreening. Round worm infections and bed buginfestations among employed third country nationalsproviding services to Coalition personnel were notuncommon.

Health hazard assessments were conducted tocharacterize exposure to the omnipresent dust, smokefrom burning solid waste, and diverse chemicals. Asthe war spiraled into a counterinsurgency, Coalitionforces moved into urban environments in and aroundBaghdad to establish JSSs and COPs. These locationswere based among existing infrastructure whererunning water was intermittent and solid wastedisposal nonexistent. This posed increased risk toCoalition personnel performing personal hygiene usinglocal water, defecating in improvised containers, andliving next to solid waste burn pits used to eliminatetrash and decrease the rodent and vector populations.Level II PM provided direct support to these austeresites which rapidly grew in number. OccupationalEnvironmental Health Surveillance at these locationswas limited due to time, the daily enemy threat, andcompeting acute health priorities.

Doctrinally, surveillance for disease and nonbattleinjury (DNBI) is the responsibility of Level III PM.Unfortunately, or fortunately depending uponperspective, the 61st Medical Detachment did notmonitor DNBIs. An excellent rapport was establishedwith the Theater Medical Command PM physicianwho monitored DNBIs and notified the 61st MedicalDetachment of patterns or trends within their area ofoperation. This allowed Level III PM to focus energyon prevention while knowing any spike in illnesswould be identified and collaboratively addressed in atimely manner. Unfortunately, this method buildsdependency and reduces recognition and assessmentskills that could be employed in a counterinsurgencyenvironment when working with host nation securityforces or the local civilian population.

MEETING THE NEED IN ACOUNTERINSURGENCY

These are just a few examples of how Level III PMaddressed doctrinal tasks during a counterinsurgency.

*Military vehicles which have been reinforced with additionalarmor to counter the affects of roadside and buried bombs,and improved penetrating direct fire munitions.

Level III Preventive Medicine in a Counterinsurgency Environment



There are other examples where the Army could learnfrom Level III successes and failures to drive change.The Army uses “doctrine, organizations, training,materiel, leadership, education, personnel, andfacilities (DOTMLPF)” as “a problem-solvingconstruct for assessing capabilities and managingchange.”6 Recent experience in Iraq and a reflection onprevious counterinsurgency operations providejustification to stimulate change within the PM fieldusing the DOTMLPF construct.

Doctrine

The global shift of populations toward urban areas andthe inability of governments to provide basic servicesfuels insurgent efforts to exploit the disenfranchised.4

Counterinsurgencies are built to address these groupsand underlying factors. Such operations are “a long,slow process that requires the integration of allelements of national power…to accomplish the tasksof creating and supporting legitimate host governmentsthat can then defeat the insurgency.”7 The Viet Congunderstood the power of PM and employed sanitationextensively in their civic action and propagandaefforts. They used slogans such as “Prevention ofDisease is Patriotism” and “Prevention of Disease isFighting the Americans.”8 Dr Richard Carmona, theUS Surgeon General, reflected on his time as a SpecialForces medic during the war in Vietnam: “PM isprobably the most important thing I learned…not onlywas I responsible for the health care of my team, butfor an entire village as well!”9 Both sides realizedinteractions between Soldiers and indigenouspopulations provided opportunities to make positiveimpressions and obtain support from the population.10

In the current situation, the shortage of internationaland nongovernmental organizations in Iraq means thatmilitary forces possess the only readily availablecapability to support the needs of the population.

Current civil-military operations (CMO) doctrinementions building host nation capacity and localsufficiency in the areas of health education, watersupply, and waste disposal.5 These areas are ripe forintervention by Level III PM working through, by, andwith host nation counterparts to fill the void inessential services, provide legitimacy to thegovernment, and stimulate the economy through jobcreation. Understanding these capabilities, the 61stMedical Detachment and the Multinational Corps-IraqForce Health Protection Officer reached out to the

Corps CMO staff. Discussions acknowledged thatProvincial Reconstruction Teams (PRTs) and CivilAffairs (CA) units have no organic PM equipment andshould coordinate with PM detachments forsupport.5,11 Offers were made to have the 61st MedicalDetachment advise, coordinate, and evaluate publichealth resources within their respective areas ofoperation to advance host nation services provided tothe population.12 Conceptual agreement was achievedand laudatory comments made, however, strategicsupport was not provided. They requested that thesubject be revisited in the future, but short term tacticalneeds dictated that Level III PM pursue other avenuesof support. As of this writing, the 61st MedicalDetachment is working with the 1st Calvary DivisionG9 CMO staff to address the significant void in publichealth and sanitation. Progress is slow. Theomnipresent challenges of PM units engaging PRT andCA personnel may be rooted in CA and PMindoctrination courses, which is explored later in thisarticle.

Organizations

The history of PM efforts highlight different, yetsynergistic capabilities between veterinary andpreventive medicine personnel, which could beemployed in Iraq and future counterinsurgencies. Forexample, when millions of Pakistanis were displacedfrom their homes, a major relief effort was mounted byPM physicians, a PM company, and 42 enlisted per-sonnel.13 This was not the 2005 earthquake disasterresponse in Pakistan, rather the relief effort followingthe flooding of the Brahmaputra River in 1954. In1963, a team of 4 physicians, 3 sanitary engineers, anentomologist, and 8 PM technicians administered41,000 doses of typhoid fever vaccine, deloused 9,000people, and treated 75 wells following intense floodingin Morocco.14 Army Veterinary Corps officers activelyparticipated in the Medical Civic Action program inVietnam where they prevented zoonotic diseases andprovided treatment and care to domestic animals.15

Unfortunately, current organizational structure withinveterinary and PM communities does not leveragecapabilities; rather, the structure fosters competition inaccomplishing similar goals.

In an effort to reduce perceived and actual food andwater inspection overlap, serious consideration shouldbe given to merging the Veterinary Food InspectionSpecialist (military occupational specialty (MOS)


68R) and PM Specialist (MOS 68S). Title the newspecialty “68RS, Public Health Specialist” andestablish doctrine and training to meet the future need.Experts in both fields have vacillated over this conceptfor years. Unfortunately, to date there has been littlerecognition of the immediate and future application ofcreating a more dynamic Soldier to meet tactical andoperational needs in counterinsurgency missions.

Building upon the public health synergy of the new68RS MOS, the organizational structure of Level IIIPM could be changed to enhance the efficiency andeffectiveness of their efforts. The current ModifiedTable of Organization and Equipment* (MTOE)assigns 13 personnel to the detachment as shown inFigure 1. Increasing the MTOE to 14 assigned with 3

additional designated personnel to be added duringdeployment (similar to the function of the ProfessionalOfficer Filler Information System16) as shown inFigure 2, could greatly enhance the detachment’scapabilities in a counterinsurgency.

Veterinary medical care is provided to Coalitionmilitary and contract working dogs in Iraq, however,

minimal engagement with indigenous animalpopulations is occurring. Team 4 of this conceptualmedical detachment could address host nation foodproduction, provide animal husbandry training, andsupport vaccination and zoonotic disease surveillanceprograms. One can argue that these missions are partof existing veterinary doctrine, but they are not beingperformed in Iraq.17 Colocating PM and veterinarymedicine assets on the same forward operating basemay facilitate coordination, but assigning both special-ties to a PM detachment would synchronize thesecapabilities toward a common goal. Conversely, thisconcept could be applied to a veterinary detachment byadding an Environmental Science/Engineer Officer(MOS 72D/E) and Public Health Specialists (MOS68RS) to their MTOE.

Additionally, the Medical Laboratory Specialist (MOS68K10) would bring a comprehensive laboratorycapability for the analysis of food, water, tissue, blood,and body fluid. Based on the experiences withlegionella, Methicillin Resistant StaphylococcusAureus, tuberculosis, Q-fever, and suspected cases ofleishmaniasis, histoplasmosis, salmonella, E. Coli, andother illnesses during the OIF 06-08 rotation, theMedical Laboratory Specialist must be qualified to testfor some of these and other infectious agents found inaustere environments. The Medical Logistics

*Defines the structure and equipment of a military organiza-tion or unit.

HEADQUARTERS

Commander (Major, MOS 72D/B*)Executive Officer (Captain, MOS 72B/D*)First Sergeant (MOS 68S40*)Mechanic (MOS 63B10*)

PUBLIC HEALTH TEAM 13 Preventive Medicine Specialists:

MOS 68S30MOS 68S20MOS 68S10





Figure 1. Current US Army Modified Table of Organization and Equipment personnel allocation forthe Level III Preventive Medicine Detachment.*MOS (military occupational specialty) glossary:

72B Entomologist72D Environmental Science Officer68S Preventive Medicine Specialist63B Light-Wheel Vehicle Mechanic




Specialist (MOS 68J10) could manage all classes ofsupply for this new detachment. A PM Specialistcurrently performs logistics duties which draws timeand effort away from the PM mission. Assignment of aMedical Logistics Specialist to the MTOE to manageunit logistics would liberate the Public HealthSpecialists to perform their public health mission.Collectively, these changes would eliminateredundancy, increase efficiency, and assist host nationsin meeting public health needs.

Training

Four years into the Iraq counterinsurgency, the PMcommunity continues to focus support internally onCoalition assets rather than externally on the civilianpopulation and Iraqi Security Forces. This lack ofpublic health integration exists for many reasons, somewithin and others outside of DoD’s control.Institutional training provides fertile ground toincrease this capacity.

HEADQUARTERS

Commander (Major, MOS 72B/D/E*)Executive Officer (Captain, MOS 72B/D/E*)First Sergeant (MOS 68RS40*)Mechanic (MOS 63B10*)Medical Supply Specialist (MOS 68J10*)


†MOS 68RS30MOS 68RS20MOS 68RS10





‡PUBLIC HEALTH TEAM 4Veterinary Officer (Captain, MOS 64B)Veterinary Technician (MOS 68T10)Medical Laboratory Technician (MOS 68K10)

Figure 2. Current US Army Modified Table of Organization and Equipment§ personnel allocationfor the Level III Preventive Medicine Detachment.

*MOS (military occupational specialty) glossary:72B Entomologist72D/E Environmental Science/Engineer Officer68S Preventive Medicine Specialist63B Light-Wheel Vehicle Mechanic

†The conceptual 68RS MOS would be created as a merger of existing MOSs 68R, Veterinary Food Inspection Specialist, and68S, Preventive Medicine Specialist.

‡Team 4 is envisioned as Army Medical Department Professional Officer Filler System (PROFIS) staffing billets. PROFISpredesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance** units to fill ActiveDuty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commandsoutside of the continental United States upon mobilization or upon the execution of a contingency operation.16

§Defines the structure and equipment for a military organization or unit.

**Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit toperform a specific mission for which there is no appropriate table of organization and equipment.


All Army PM officers attend the Principles of MilitaryPreventive Medicine indoctrination course. Theprogram of instruction (POI) consists of 585.4 hours ofcommon core, clinical, and science track instruction.18

A review of the common core and science trackcourses which are completed by nonclinicians revealsthat only 11 hours (3%) are focused on materialdirectly or indirectly related to counterinsurgencies(Table 1).

Although other classes, such as water quality analysis,develop competencies which can be applied incounterinsurgencies, these classes do not drawcorrelation between the two. Further analysis revealed14 hours of instruction (Table 2) provided during theclinical track relate to counterinsurgencies. Theseclasses should be incorporated into the common coretrack to increase the capabilities of all PM officers.Serious consideration should be given to addingcourses highlighting root causes of counterinsur-gencies and effective employment of Army PM insupport of civil-military operations.

Concurrent with changes in training delivered withinthe AMEDD POIs, further development of externaltraining must also be addressed. As previouslyindicated, aggressive efforts were made by the 61stMedical Detachment to engage CA personnel, withlittle return on investment. This limited success was

certainly not due to a lack of effort, rather, thedifficulties were a result of what was routinelyobserved as a lack of education. CA officers in theaterunderstood the significant impact water and sanitationhave during a counterinsurgency. Unfortunately,discussions with both seasoned and new CA Officersrevealed that they had received minimal training onhow to leverage PM in bridging public health gaps.CA doctrine discusses PM, but what emphasis isplaced on this battle operating system during initialtraining is unknown to the author.12 A comprehensiveanalysis of their course POI could identify wheretraining deviates from doctrine, and how Army PMcould provide training assistance. Cross-training CAand PM personnel could create a symbioticrelationship yielding substantial dividends duringcounterinsurgencies.

Recent experiences in Iraq continue to identifyprofound shortfalls in the Army Field Sanitation Team(FST) program.19 The program is conceptually ac-cepted by all levels of command, but implementationis lacking. Many perceive the FST course as nothingmore than an avenue to obtain enlisted promotionpoints. Team members are assigned on paper but losecurrency or complete the task only if time permits.Most unit commanders do not procure FST equipmentdue to high costs, other priorities, and time. Theestablishment of a single National Stock Number tostreamline the FST kit would reduce the time spenttracking numerous line items found in the current kitand increase commander compliance. Army medicsadopted the FST responsibility in Iraq with directsupport from Level II PM personnel. Is it morepractical to add FST classes to the Army medic POI


Title Hours

Army HIV Program 1

Introduction to Humanitarian AssistanceOperations 1

Malaria Prevention 1

Preventive Medicine Support for Disasters 1

Population Health 1

Disaster Relief Practical Exercises 2

Nutrition Concerns in Disaster Relief 2

Preventive Medicine Aspects of DetaineeOperations 2

Table 1. Common core/science track counterin-surgency related classes taught in US Army Course6AF5 - Principles of Military Preventive Medicine.

Table 2. Clinical track counterinsurgency relatedclasses taught in US Army Course 6AF5 - Principlesof Military Preventive Medicine.

Title Hours

Rapid Health Assessment 1

Public Health Assessment 1

Civil Affairs and Foreign Government Liaison 2

Implications of Emerging Infectious Diseases 2

Preventive Medicine Support in ContingencyOperations 8



and have them assume the mission? This may be adesirable situation upon which the Army shouldcapitalize.

A net gain in FST training was made by the 61stMedical Detachment during OIF 06-08. The decisionto shift training from Coalition members to the IraqiSecurity Forces was made upon arrival, and consensuswas reached at the strategic level to replicate this effortthroughout theater. Training host nation military andcivilian populations in PM is essential to sustain theirfighting force and build basic sanitation capacity.Cultural implementation of these newly acquired skillswill not occur overnight, but they are essential inmeeting short and long term needs of the population.

Materiel

Coalition personnel in Iraq are working alongside theISF and operating out of austere joint security stations.Level III PM is supplying some of those stations andArmy-led Military Transition Teams with basic FSTequipment to meet urgent needs in controlling vectorsand purifying water. Despite the regulationrequirement for supplies, they do not have theresources on hand for many reasons.20 It should beassumed that similar scenarios will exist in futurecounterinsurgencies and Level III PM must beequipped with additional kits to support those in need.

Insurgents will continue to pursue the use of toxicindustrial chemicals and weapons of mass destruction.Increasing the Level III detachment’s direct chemicalreading capability to measure contaminant levels is acritical requirement. The INFICON (Two TechnologyPlace, East Syracuse, New York 13057) HAPSITE®

gas chromatograph/mass spectrometer, and Smiths(Smiths Detection, 21 Commerce Drive, Danbury, CT06810) HazMatIDTM portable chemical identifier usedby the Army Area Medical Laboratory and NavyForward-Deployed Preventive Medicine Unit providethis much needed capability. Neither of these Level IVPM units were in theater during OIF 06-08, whichplaced higher expectations upon Level III PM toexecute missions they were ill-equipped to perform.

Leadership

The current Army PM leadership was shaped byexperiences during the first Gulf War (1991) and theBalkan deployments—a conventional war and peacekeeping operations. Much of their work led to the

development and implementation of the OccupationalEnvironmental Health Surveillance (OEHS) programwhich is easily implemented in a linear battlefield andsemipermissive environment.21-23 This programcaptures data to analyze acute, chronic, and delayedhealth effects, primarily through air, soil, and watersampling.23

Recent events in Iraq led to reprioritizing the acutepublic health needs over the OEHS sampling mission.OEHS results from the US Army Center for HealthPromotion and Preventive Medicine (CHPPM) wereprovided to the 61st Medical Detachment, on average,91 days after sample shipment for air, 52 days for soil,and 59 days for water. Level II PM experiencedsimilar turnaround times resulting in a de-emphasis onOEHS sampling in lieu of addressing acute needsusing real time analysis equipment. This wascounterintuitive for some Level II PM officers whoperceived OEHS air, soil, and water sample collectionas their primary mission and lifeline to definitiveanswers. The PM community and leadership mustaddress the OEHS sampling and documentationrequirement in a counterinsurgency environment withresources currently available. It may be more realisticto have Level II and III PM personnel conduct initialbase camp OEHS sampling within their areas ofoperation and Level IV PM conduct routine and basecamp closure OEHS sampling in conjunction with theArmy Corps of Engineers. Serious discussion mustalso address this requirement and how PM measureseffectiveness. One could argue that OEHS samplingdoes not tie directly to DNBI statistics which is thecurrent default measure of PM success or failure.

The effectiveness of Level III PM detachments in thefield is directly dependent on Soldiers that the Armyrecruits, develops and places in positions of leadershipand command. In the final analysis, without dedicated,intelligent, well-trained, professional leadership, noneof the other factors discussed herein will matter in theperformance of these detachments. Leaders in highercommand positions must have the full spectrum ofinsight and understanding as to the capabilities andultimate, long-term strategic value represented by theLevel III PM resource. Only then will the assets beintelligently applied and adequately supported. Thatcommand perspective comes from education andtraining in the strategic considerations ofcounterinsurgency operations, combined with theinsights and understanding that only result from actual


experience developing and employing the Level IIIPM resources.

Over the next 5 to 10 years, leaders within the PMcommunity will draw upon observations and lessonslearned during the Balkan deployments and initialphases of OEF and OIF. Over the long term, Level IIPM personnel currently serving in Iraq will assumeleadership roles. Their counterinsurgency experiencewill likely drive changes in core competencies, with anemphasis on acute and general public healthintervention, to meet what is perceived by many as theconflict of the future.7,24,25

Personnel Recruitment

Level III PM detachments are commanded by fieldgrade Entomologist (MOS 72B) and EnvironmentalScience/Engineer (MOS 72D/E) officers, which makethese 2 specialties of particular interest in assessingrecruitment and retention. The Army objective forcefor these officers is 346, with a current strength of 335(97% fill). From 2004 to 2006, the objective force forthese professions was 72 officers, of whom 61 (85%)are commissioned.26 They joined through directcommissions following graduate school, collegeReserve Officer Training Corps, or the US MilitaryAcademy. Some, like the author, convert to PM afterserving as a Health Care Administrative Assistant(MOS 70B). Assuming that not all of the 61commissioned officers will serve a career in themilitary could justify pursuing other recruitmentavenues. A study assessing conversion trends fromMOS 70B to the MOS 72 series may justify amarketing campaign to recruit these officers comingout of multiple OIF rotations. They would bring a firsthand understanding of how PM can support thewarfighter during a counterinsurgency.

Supporting the field grade Level III PM detachmentcommanders are company grade executive officersserving in these specialty areas. A review of activeduty Army company grade Environmental Science/Engineer officer authorizations revealed that half werein garrison assignments.27 Forty-six percent oflieutenants and 53% of captains were assigned to fieldunits, 26% and 25% respectively to CHPPM, and 28%and 22% respectively to Army medical centers or otherorganizations. In the perspective of an Army at war,this appears disproportionate to the current and futurerequirements. In 2006, the Army PM Consultant poseda salient question in the Army Medical Department

Journal: “Should some MEDDAC ESO [medicaldepartment activity environmental science officer]positions be converted under current military-to-civilian initiatives in order to provide betterdevelopmental opportunities for junior officerselsewhere?”28 It could be argued there is no betterplace to apply and develop skills than during combatdeployments by conserving the fighting strength ofthose in harm’s way. Reducing garrison positionscould shift personnel to meet current PM shortages indeployable multifunctional medical battalions, andafford growth in areas such as newly activated civilaffairs battalions and each regional special operationscommand. Experience in these assignments wouldgenerate skills necessary to effectively serve as both aLevel III PM detachment executive officer andcommander in a counterinsurgency environment.

Similar analysis should be completed to assess theproposed merger of the Veterinary Food InspectionSpecialist (MOS 68R) and Preventive MedicineSpecialist (MOS 68S) in the enlisted force structure.Ultimately, they will serve as Level III PM detachmentmembers, NCOs, and detachment sergeants whoexecute the unit mission. It is imperative to solicitfeedback from both recently returned and currentlydeployed PM and veterinary personnel, as theyunderstand the current operational requirements. Acomprehensive review of the manning document forthe existing MOSs is necessary to shape futureauthorizations for the proposed Public HealthSpecialists (MOS 68RS). Other proposed changes,such as replacing the current MOS 68S level 10(Private First Class through Specialist) at each Armybrigade with a MOS 68S level 30 (Staff Sergeant),must be considered, since these positions will drivemanning requirements.29

Personnel Retention

Numerous media outlets discuss the potential impactof high operational demands on retention. Accordingto the DoD, “Army, Navy, Marine Corps, and AirForce met or exceeded overall retention missions.”30

What is not clear are retention rates in the PMcommunity. Unlike most officers who enter Army PMwith a degree related to their chosen field, and with theintention of directly applying that education, enlistedPM personnel are selected and trained by the Army invarious skill sets necessary for their MOS. At specificpoints in the enlisted career path, the Army offersadditional training of increasing sophistication to




support their respective specialties. However, theArmy also regularly offers opportunities andincentives for Soldiers to change to another MOSspecialty altogether, depending on staffing prioritiesand shortfalls at the time. Any Soldier considering along-term career in PM will evaluate opportunities intheir field against those opportunities represented inanother MOS or civilian life, and make a rationaldecision. With low promotion rates to Sergeant FirstClass (grade E7) and above, due in part to the scarcityof senior PM level positions, this weighs heavily in theminds of Staff Sergeants (grade E6). These NCOstypically have 10 years in service and debate whetherto continue their profession, reclassify, or leave themilitary. Unless the PM enlisted authorizations areadjusted to support and encourage the pursuit ofcareers by our enlisted Soldiers, the effectiveness andmanning of Level III PM will be less than optimum.Increasing senior level enlisted PM authorizationsallowing for professional growth commensurate withtime invested could make a difference. Adding MasterSergeant (grade E8) positions to combatant and otherstrategic commands where Environmental Science/Engineer officers currently serve would be a forcemultiplier, allow for professional growth andpromotion, and positively impact retention rates.Additionally, investing in the long term education ofboth may provide an impetus to serve a career inuniform.

The Army PM leadership took the initiative in 2004and crafted an education and training program bysending Environmental Science officers to theUniformed Services University of the Health Sciencesto complete a one-year Master of Public Health degreefollowed by a one-year utilization tour in Washington,DC. These officers can specialize in areas such asinternational health which has applicability in bothdisaster response and counterinsurgency operations.Upon graduation, the officer could work at DoD ormilitary service headquarters levels, or othergovernmental agencies, such as the Department ofState or US Agency for International Development,applying their skills to real world requirements.Assignments in other agencies broaden theirunderstanding of interagency operations and meet theintent of DoD Directive 3000.05, Military Support forStability, Security, Transition, and ReconstructionOperations31 and the Quadrennial Defense Review.25

Facilities

Proposed consolidation of all services’ enlistedmedical training at Fort Sam Houston, Texas as part ofthe Base Realignment and Closure process iscommended and should be replicated among othermedical specialties. Consolidation of training effortscould reduce duplication in facilities, operations andmaintenance costs, and personnel required to conductsimilar training programs at 3 different serviceinstitutions while increasing productivity anddeveloping a joint PM service member. Experience inIraq highlights similarities in capability between AirForce, Army, and Navy professionals performing PMtasks. Current doctrine drives requirements for eachservice where the Navy traditionally focused onmaritime operations, the Air Force on wing support,and the Army on the foot Soldier. In thecounterinsurgency environment of Iraq, NavyEnvironmental Health officers are collocated onforward operating bases with Army Soldiers. Air ForcePublic Health and Bio Environmental Engineerofficers/technicians are working shoulder to shoulderwith Army personnel on large air bases. The 61stMedical Detachment provided general area PMsupport to all service personnel within multinationaldivisions in Baghdad and central Iraq during the OIF06-08 rotation. Additionally, all 3 services receivedOEHS equipment and laboratory support from the USArmy Center for Health Promotion and PreventiveMedicine for the OEHS mission while deployed inIraq. It is imperative that leaders within each servicerecognize the similarities in capabilities andrequirements to develop a common set of knowledge,attitudes, and beliefs for a joint service PM trainingplatform. This platform should be institutionalized at aconsolidated PM training facility at Fort Sam Houston.

CONCLUSION

The 2006 DoD Quadrennial Defense Review states:…the ability to wage irregular and unconventional war-fare and the skills needed for counterinsurgency,stabilization and reconstruction, military diplomacy,and complex interagency coalition operations areessential.25

Adoption and implementation of the aforementionedDOTMLPF changes could facilitate transformationwithin the PM community to meet these current andfuture demands, and directly support overarching USgovernment efforts in rebuilding essential services in


fragile societies. As recently observed in Iraq, andhighlighted by the National Security Strategy signedby President George W. Bush:

Military involvement may be necessary to stop a bloodyconflict, but peace and stability will last only if follow-on efforts to restore order and rebuild are successful.32

Preventive Medicine can support both undertakings.

REFERENCES

1. Krepinevich AF Jr. The Army and Vietnam.Baltimore, MD: Johns Hopkins University Press;1986:6.

2. Joint Publication 1-02: DoD Dictionary of Militaryand Associated Terms. Washington, DC: Joint Staff,US Dept of Defense; July 12, 2007. Available at:ht tp : / /www.d t ic .mi l /doct r ine / j e l /new_pubs/jp1_02.pdf.

3. Field Manual 3-24: Counterinsurgency. Washington,DC: US Dept of the Army; 15 December 2006:1-1,2-13.

4. Chiarelli PW, Michaelis PR: Winning the peace: therequirement for full-spectrum operations. Mil Rev.2005;4:4-17.

5. Field Manual 4-02.17: Preventive Medicine Services.Washington, DC: US Dept of the Army; 28 August2000:4-1,4-10.

6. Field Manual 1: The Army. Washington, DC: USDept of the Army; June 2005:4-3,4-4.

7. Nagl JA. A better war in Iraq. Armed Forces J.A u g u s t 2 0 0 6 . Av a i l a b l e a t : h t t p : / /www.armedforcesjournal.com/2006/08/1931298.

8. Ahearn AM. Viet Cong medicine. Mil Med.1966;131:219-221.

9. Carmona RH. Presentation to the National DisabledVeterans Winter Sports Clinic. Aspen, CO: 2003.

10. Field Manual-Interim 3-07.22: Counterinsurgency.Washington, DC: US Dept of the Army; 1 October2004. Replaced by FM 3-24, 2006.

11. US Dept of State. Fact Sheet on ProvincialReconstruction Teams. Baghdad, Iraq: Embassy ofthe United States; 2006.

12. Field Manual 4-02.43: Force Health ProtectionSupport for Army Special Operations Forces.Washington, DC: US Depart of the Army; 27November 2006:4-11,4-12.

13. Erickson RL. Military Preventive Medicine:Mobilization and Deployment. Vol 1. Washington,DC: Borden Institute, Office of the Surgeon General,US Dept of the Army; 2003:81-98.

14. Keating PJ. Moroccan flood relief: a personal report.Med Bull US Army Eur. 1963;20(4):96-99.

15. Webb CR Jr. Medical considerations in internaldefense and development. Mil Med. 1968;133:391-396.

16. Medical Corps Professional Development Guide.Fort Sam Houston, TX: US Army MedicalDepartment Center and School; March 2002:27.

17. Field Manual 4-02.18: Veterinary Service Tactics,Techniques, and Procedures. Washington, DC: USDept of the Army; 30 December 2004:1-1,4-7.

18. US Army Medical Dept. Principles of MilitaryPreventive Medicine Program of Instruction. FortSam Houston, TX: US Army Medical Dept Centerand School; 2003.

19. Field Manual 4-25.12: Unit Field Sanitation Team.Washington, DC: US Dept of the Army; 25 January2002:1-1,2-75.

20. Army Regulation 40-5: Preventive Medicine.Washington, DC: US Dept of the Army; 25 May2007:1-19.

21. Department of Defense Directive 6490.2:Comprehensive Health Surveillance. Washington,DC: US Dept of Defense; 21 October 2004:1-6.

22. Department of Defense Instruction 6490.03:Deployment Health. Washington, DC: US Dept ofDefense; 11 August 2006:5-13.

23. Army Regulation 11-35: Deployment Occupationaland Environmental Health Risk Management.Washington, DC: US Dept of the Army; 16 May2007:1-9.

24. Hammes TX. The Sling and The Stone.. St. Paul,MN: Zenith Press; 2004:xiii-xiv,224-291.

25. Office of the Secretary of Defense. QuadrennialDefense Review Report. Washington, DC: US Dept ofDefense; February 6, 2006.

26. Army Medical Service Corps. Career ManagementHistograms. Alexandria, VA: US Dept of the Army;December 2006.

27. Army Medical Service Corps: MOS 67C Roster.Alexandria, VA: US Dept of the Army; February2007.

28. Ciesla JJ. The evolving role of EnvironmentalScience Officers and Environmental Engineers in theMedical Service Corp. Army Med Dept J. April-June2006:19.

29. Sames WJ, Delk TC, Lyons PJ: Field preventivemedicine: challenges for the future. Army Med DeptJ. April-June 2006:43.




30. DoD Announces Recruitment and Retention Numbersfor June [press release]. Washington, DC: Office ofthe Assistant Secretary of Defense (Public Affairs),US Dept of Defense:2007.

31. Department of Defense Directive 3000.05: MilitarySupport For Stability, Security, Transition, AndReconstruction (SSTR) Operations. Washington, DC:US Dept of Defense; November 28, 2005:1-11.

32. The National Security Strategy of the United States ofAmerica 2006. Washington, DC: The NationalSecurity Council, The White House; March 2006:16.Available at: http://www.whitehouse.gov/nsc/nss/2006/nss2006.pdf.

AUTHOR

MAJ Licina is Commander, 61st Medical Detachment,86th Combat Support Hospital (CSH), Fort Campbell,Kentucky. The 86th CSH is a part of the 44th MedicalCommand at Fort Bragg, North Carolina.

86th Combat Support Hospital

44th Medical Command


The Chemical, Biological, Radiological, and HighYield Explosives (CBRNE) Sciences Branch*provides training to a diverse group of students,including members of the various US military services,foreign students, and civilians on medical operationson the nuclear, biological, chemical, or directed energybattlefield; as well as the safe use of radiation andradioactive materials. In 2007, the CBRNE SciencesBranch taught the 5-day Tactical RadiologicalOperations (TRO) Course at the Idaho NationalLaboratory, Idaho Falls, ID. The TRO course wasdeveloped and has evolved in response to lessonslearned after 4 years of deployments in support ofOperation Enduring Freedom (OEF) and OperationIraqi Freedom (OIF). The gap analysis suggested thattraditional health physics training designed for hospitaland garrison environments did not provide theinstruction and focus that Nuclear Medical ScienceOfficers need when dealing with radiological hazardsin nonmature theaters of operation.

The regulatory constraints on the use of licensedradioactive material limit the ability of the ArmyMedical Department Center and School(AMEDDC&S) to provide real world situations wherehealth physics training would more closely replicatedeployment and homeland defense scenarios. At theIdaho National Laboratory, the Department of Energywas able to provide, at one location, access to a uniquecombination of facilities, radioactive materials, andtrained professional staff that cannot be duplicated atany Department of Defense facility. In order to bridgetraining gaps, the CBRNE Sciences Branch and the USArmy Chemical School coordinated with the IdahoNational Laboratory to accommodate OEF and OIFscenario-driven environmental health physics training

for military personnel. The TRO course consists ofdidactic health physics training, radiation detection/identification equipment training, high energyradioactive source identification and quantification,and radiological dispersal device training thatculminated with a field training exercise incorporatingbasic military skills and team technical skills. It is alsodesigned to facilitate small team training andinteraction with training scenarios to provideopportunities for both individual leadershipdevelopment and team problem solving.

Across the Army manpower structure, there are manydifferent military occupational skills that have similarmilitary knowledge requirements. This is true forradiological operations for some medical, chemicalcorps, and engineering disciplines. In order to broadenthe availability of quality subject matter experts toaddress multiple mission requirements for suchspecialists, the TRO course is offered for Environ-mental Science and Engineering Officers and Chem-ical Operations Specialists.

The 2007 scenarios included:

Tactical movement of a survey team into alocation to conduct a base camp assessment forradiological hazards

High energy radioactive source identification andmitigation to include exposure guidance forpersonnel

Decontamination of personnel exposed to weaponsgrade or other nuclear materiel

Encounters with media personnel regardingpotential radioactive contamination to military andhost nation personnel

Preparing the Force for the Chemical,Biological, Radiological, and High YieldExplosives Battlefield; Today and Tomorrow

LTC Gary Matcek, MS, USAScott Crail, MS

SFC Courtney Moore, USAJames Bernardo

*Department of Preventive Health Services, AMEDD Center andSchool


The critical tasks accomplished were:

Selection of the proper radiation detection/identification equipment for a given mission.

Proper operation of radiation detection/identification equipment for a given mission.

Design radiological survey using Technical Guide236A; Basic Radiological Dose Estimation – AField Guide,1 and then brief the brigadecommander.

Conduct radiological survey of area to includesoil, air, and water sampling.

TESTING AND FIELDING NEW EQUIPMENT

Recently, the CBRNE Sciences Branch participated inseveral meetings about the development of the newXM-329 Joint Chemical, Biological andRadiological Agent Water Monitoring System(JCBRAWM). The system is underdevelopment by the US Chemical Corps toaugment the M272 Water Test Kit in responseto the Army’s identification of the need toexpand the M272 capability to include the fullspectrum of CBRNE threats. The requirementfor expansion in capabilities is the result ofrecent threats in the areas of homelandsecurity and homeland defense. TheJCBRAWM consists of the AN/PDR-77Radiac Detector Set which tests water forpossible radiological contamination, the HandHeld Assay for possible biologicalcontamination, and the standard M272 WaterTest Kit for chemical contamination.

As the Nuclear Medical Science Officers andPreventive Medicine Specialists execute their wartimemission of base camp assessment, the enhancedcapability provided by the JCBRAWM will furtherimprove the safety and survivability of all Soldiers onthe battlefield by ensuring that water sources are at anacceptable level of cleanliness and purification forconsumption. In addition, it will increase the capabilityof the US Chemical Corps to identify which natural ormanmade water sources should or should not be usedfor personal or equipment decontamination.

As a further complement to the type of equipment thatwill be used to sample and test water, the US ChemicalCorps has enhanced the immediate personneldecontamination capability of the Army by developingthe Reactive Skin Decontamination Lotion (RSDL).

The new lotion provides a Soldier with the capabilityto perform on-the-spot decontamination without thenecessity of the full spectrum decontamination line—amanpower intensive process. Through the use of theJCBRAWM and the RSDL, the Preventive MedicineSpecialist will now have the ability to conduct on-the-spot chemical, biological, and radiological testing,with the added capability for personal and equipmentdecontamination.

Both AMEDD and the Chemical Corps will benefitfrom these recent new equipment developments. Eventhough JCBRAWM development testing is notcomplete, the CBRNE Sciences Branch will continueto represent the Army Medical Command in advisingthe developmental team to ensure optimum usabilityby Preventive Medicine Specialists.

A STANDARD OF PROFICIENCY FOR FIXED

MEDICAL TREATMENT FACILITIES IN ALL-HAZARDS RESPONSE

A hazardous material incident involving CBRNEhazards or other threats, whether accidental orintentional, has the potential to produce catastrophicloss of life or property, or strike terror in the affectedpopulation. An incident may occur in the US oroverseas. The Army Training and Evaluation Plan–Mission Training Plan for US Army fixed installationmedical treatment facilities (MTF) provides hospitaland clinic commanders and staff with a descriptive,mission oriented program to train the facility staff toperform its critical operations during such an event.

Joint Chemical, Biological, and Radiological Agent WaterMonitoring System (JCBRAWM)


While US Army Medical Command directives,national healthcare standards, and local conditions andprocedures dictate unique training requirements andperformance standards, the Mission Training Plandescribes many of the tasks that any staff of a hospitalor clinic may be called upon to execute with a highlevel of proficiency. The commander of each facility isnot expected to train on every single task in theMission Training Plan; rather, tasks are selected andprioritized based on an assessment of an MTF’sstrengths and weaknesses, and on those tasks thatfocus on training deficiencies that impact on theMTF’s ability to perform its first receiver mission.

The CBRNE Science Branch was assigned the task todevelop an Army Training and Evaluation Plancontaining individual, collective, and leader tasks forfixed military MTFs to support installation protectionmissions and plans for CBRNE and all other hazards.The training documents traditionally have a unit/activity doctrinal manual to provide operatingprinciples and techniques that allow the trainingdeveloper to analyze and enumerate collective tasksfor the entity. In this case, there was no baselinepublication for fixed installation MTFs, thus, the teamrelied on an extensive literature review to help developthe tasks.

The unit, leader, and individual training syllabi supportthe accomplishment of both Homeland Securitymissions and traditional full spectrum militaryoperations. Therefore, current doctrinal manuals,Army Training and Evaluation Plan–Mission TrainingPlans, and federal government response guidelinesoffer a wealth of information on training tasks that canbe adapted for installation MTFs. According to theArmy Training and Doctrine Command Regulation350-70,2 a revision of tasks rather than a full-scaledevelopmental effort is preferred for training similarmissions in a different environment or setting. Byidentifying tasks from current documentation, the teamcan build a basic outline from which to further analyzeand refine required CBRNE tasks for a fixed MTF.

Once candidate tasks have been defined, a mission/jobanalysis must still be conducted to identify criticalcollective tasks. This is a key step, since the collectivetasks performed to accomplish a unit or MTF missionwill drive the development or revision of individualand leader tasks that directly support the mission.

Mission analysis identifies unit organizational andfunctional structure before development of unittraining products.

Armed with baseline collective, leader, and individualtasks, members of the team and a governmentrepresentative will conduct site visits to MTFs. This isrequired to receive input from the MTF commanderand staff and to analyze candidate tasks within thecontext of existing installation plans and standardoperating procedures.

As a result of site visits and continuing analysis anddevelopment, a list of proposed collective, leader, andindividual tasks are presented for review. An exampleof proposed tasks in support of CBRNE events are:

Perform public health emergency officer functions

Conduct termination planning

Conduct interagency coordination

Review and update CBRNE incident response plan

A task validation board or some other proponentmechanism will then be convened for further reviewand selection to approve the proposed tasks. Once thatapproval is received, the training developers will enterthe tasks into the Automated Systems Approach toTraining.

The trainers/evaluators will develop and present atraining evaluation plan based on the approvedcollective, leader, and individual tasks. Trainingevaluation is the process used to identify taskperformance and deficiencies in unit and individualtraining, and to obtain recommendations forimprovement of training, or the products that supporttraining. There is no specific procedure prescribed forArmy Training and Doctrine Command proponents inthe development or conduct of unit training evaluation.The procedures selected are dependent upon a varietyof factors, including, in this case, the MTF real-worldworkload, whether the unit can be visited by externalevaluators, whether actual training execution can beobserved, and how many unit personnel are availableto participate in an exercise or other evaluationvehicle. By its very nature, CBRNE response exercisesin a Homeland Security scenario require enormousamounts of coordination and resources from local,state, and federal agencies and role players to provide

Preparing the Force for the Chemical, Biological, Radiological, andHigh Yield Explosives Battlefield; Today and Tomorrow



the proper test conditions. Therefore, standard Armyand AMEDD evaluation regimens may yield to theDepartment of Homeland Security and/or stateemergency management evaluation schedules andrequirements. Individual and leader task evaluationscan be done in the schoolhouse or at the MTFs by useof student performance measurement and testing,including practical exercise, and therefore lendthemselves to a regular assessment schedule withoutthe need for a large commitment of resources. Theevaluators will take these factors and AMEDDguidance into account in development of theevaluation plan.

Training and evaluation exercises for a fixed MTF areinherently difficult for the commander for a variety ofreasons. Most notably, the hospital or clinic mustperform real-world missions, resulting in severe timeand resource constraints for training missions, whichimpact personnel availability issues. Despite the needto perform day-to-day operations, the facility musttrain and undergo periodic evaluations in accordancewith directives, not only from higher command, butfrom civilian agencies such as the Joint Commissionon Accreditation of Healthcare Organizations and the

Department of Homeland Security. The strategyselected by the commander for training MTFdepartments must include various methods of trainingindividuals, designated staff, leaders, and thedepartment and facility staffs as a whole.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the assistance ofEric Bodenhausen, Jose Perez, and Doug Hanson fortheir editorial review and comments.

REFERENCES

1. Technical Guide 236A, Basic Radiological DoseEstimation – A Field Guide. Aberdeen ProvingGround, MD: US Army Center for Health Promotionand Preventive Medicine; August 15, 2001. Availableat: http://chppm-www.apgea.army.mil/documents/tg/techguid/tg236a.pdf.

2. TRADOC Regulation 350-70: Systems Approach toTraining Management, Processes, and Products. FortMonroe, VA: US Army Training and DoctrineCommand; March 9, 1999:chap II-11. Available at:http://www-tradoc.army.mil/tpubs/regs/r350-70/350_70_ii_11.htm.

AUTHORS

LTC Matcek is the Officer in Charge, CBRNE Sciences Branch, Department of Preventive Health Services, AMEDDCenter and School, Fort Sam Houston, Texas.

Scott Crail is a Senior Radiological CBRNE Instructor, CBRNE Sciences Branch, Department of Preventive HealthServices, AMEDD Center and School, Fort Sam Houston, Texas.

SFC Moore is the Noncommissioned Officer in Charge, CBRNE Sciences Branch, Department of Preventive HealthServices, AMEDD Center and School, Fort Sam Houston, Texas.

Mr Bernardo is a Project Manager, Training Developer, and Instructor, CBRNE Sciences Branch, Department ofPreventive Health Services, AMEDD Center and School, Fort Sam Houston, Texas.


OVERVIEW

On 15 September 2005, President Bush endorsed theDepartment of Defense (DoD) Base Closure andRealignment Commission’s (BRAC) report andforwarded it to Congress. The congress had 45legislative days, until November 9, 2005, to accept orreject the report in its entirety. However, it was notauthorized to make any changes to the final report.1

Since the congress took no action before the deadline,the BRAC recommendations became law. By statute,DoD had until September 15, 2007, to initiate closingand realigning the installations specified in the report.Additionally, the process must be completed bySeptember 15, 2011.2

Included in the BRAC recommendations wasCommission Recommendation 172, San AntonioRegional Medical Center, Texas.3 It is within thisrecommendation that the concept of the MedicalEducation and Training Campus (originally submittedunder BRAC as the Medical Enlisted Training Center)was established. The recommendation specifically wasto relocate “…all (except Aerospace Medicine)medical basic and specialty enlisted training at FortSam Houston, Texas, with the potential oftransitioning to a joint training effort.”4 In response tothe requirement for the Medical Education andTraining Campus, the Army Medical DepartmentCenter and School (AMEDDC&S) directed itssubordinate teaching departments to coordinate withthe Interservice Training Review Organization(ITRO). The ITRO then conducted meetings amongthe services to determine if courses would collocate orintegrate. The specified construct was:

Quick Look Group

Detailed Analysis Group

Resources Required Analysis

While this process is uniform for all, the remainder ofthis article will focus on its application to PreventiveMedicine.

QUICK LOOK GROUP

The Preventive Medicine Quick Look Group,composed of the Army 68S10* Program Manager,Class Advisor, and Instructional Systems Specialist;and the Navy Program Manager, Service Lead, andInstructional Systems Specialist; along with variousITRO staff, met from September 12-14, 2006. This 3-day initial study revealed sufficient commonalityexisting between the US Army Preventive MedicineSpecialist Course† and the US Navy PreventiveMedicine Technician Course‡ to propose consolidatinga majority of the training and recommend continuingthe ITRO process. The members of this Quick LookGroup agreed to future meetings to develop aconsolidated curriculum and identify computer basedtraining opportunities. It was agreed that membershipof these studies should include the current participants.The Quick Look Group made the following specificrecommendations:

Ensure a joint services curriculum and requiredsupport facilities will be in compliance withcurrent certification/accreditation requirements.

Coordinate proposed facilities plans with servicesubject matter experts.

Due to shipboard and Fleet Marine Force trainingrequirements, Navy students must have phase II,Navy specific sites (ie, shipboard training).

Phase II sites will require dedicated instructorstaff.5(p6)

The Army Preventive Medicine Specialistin the Medical Education and TrainingCampus Era

LTC Dennis B. Kilian, MS, USASFC Roye L. Patton, USA

HMCS William Adams, USN

*Army Military Occupational Specialty 68S10, PreventiveMedicine Specialist

†Army Training Course 322-68S10‡Navy Training Course HM 8432


Since the US Air Force enlisted preventive medicinepersonnel are considered part of the aerospacemedicine community, their training will relocate fromBrooks City Base, San Antonio, TX, to Wright-Patter-son Air Force Base, Dayton, OH. Consequently, theAir Force is not part of the BRAC-driven preventivemedicine training review and reorganization.

DETAILED ANALYSIS GROUP

The meeting of the Preventive Medicine DetailedAnalysis Group was held March 6-8, 2007. Themilitary training personnel who were previously partof the Quick Look Group conducted an in-depthanalysis of the 2 programs of instruction (POI)conducted in the training of service specific preventivemedicine personnel.

The Army trains Preventive Medicine Specialists(Military Occupational Specialty 68S10) for 15 weeks(75 academic days) at the AMEDDC&S, Fort SamHouston, Texas. For planning factors, the Armytraining requirement for Fiscal Year (FY) 2010 is 209students. The basic course* consists of 532 hours ofdidactic/laboratory/practical training, and 110 hours offield training exercises and situational trainingexercises—a total of 642 academic hours. At the timeof review by the Detailed Analysis Group, there were7 class iterations per year, with a maximum classpopulation of 32 students, minimum of 12 students,and an average of 21. The enrollment pay grade forActive Army Soldiers is E4 or below, E6 or below formembers of the Reserve Component. As a part of thePOI, students must pass specified areas of the DoDPest Management Certification exam. Additionally,they are offered the opportunity to take the ServSafe®

certification examination.†

The Navy trains Preventive Medicine Technicians(PMT) for 26 weeks (130 academic days) at the NavalSchool of Health Sciences, San Diego, California. TheNavy training requirement for FY 2010 is 160students. The Navy uses multiple clinical and fieldtraining sites, including ships, fixed facilities, and localcivilian facilities. The PMT basic course consists of844 hours of didactic/laboratory/practical training

(including a 160-hour course: Medical Entomologyand Pest Management Technology for PMTs), and 64hours of other required training and activities. Thetraining totals 1,040 hours. At the time of review bythe Detailed Analysis Group, there were 4 classiterations per year, with a maximum class populationof 40 students, minimum of 20 students, and anaverage of 40. The enrollment pay grade for activeduty Navy is E3 through E7. This course is open toNavy Reserve and Coast Guard personnel. As a part ofthe POI, students are required to pass specified pestmanagement categories of the DoD Pest ManagementCertification exam. Students may take the CertifiedEnvironmental Health Technician exam from theNational Environmental Health Association.5(p6)

During the Detailed Analysis Group working sessions,the Army and Navy representatives presented severalconcerns for further examination:

Army

AMEDDC&S will be able to continue to inviteinternational students to attend preventivemedicine training.

Ensure that food service sanitation remains in thecurriculum to enable Army students tosuccessfully pass the ServSafe Exam.5(p5)

Navy

Scope of practice – a concern because Navy PMTsoperate clinically, unlike Army preventivemedicine personnel.

Course content – considered an opportunity sinceJoint Occupational and Environmental HealthSurveillance is largely undocumented in the NavyPOI5(p5) (current requirements driven by a DoDDirective,6 a DoD Instruction,7 and amemorandum from the Chairman of the JointChiefs of Staff 8).

Requirement for a Phase II clinical site – sincethere are no shipboard environment trainingfacilities at Fort Sam Houston, teaching shipboardpractices would be problematic.

Accreditation/certifications – maintaining accredi-tation/certifications was viewed as a criticalrequirement, which is consistent with otherprograms relocating and integrating into theMedical Education and Training Campus concept.

*Army Training Course 322-68S10†The ServSafe Food Safety Certification is a risk managementprogram of the National Restaurant Association EducationalFoundation. ServSafe is the most widely accepted food safetyprogram among local, state, and federal health departments.Information available at http://www.nraef.org.


As a result of the work of the Preventive MedicineDetailed Analysis Group, a recommendation for thecore consolidation of approximately 449 hours ofinstruction was submitted. The resultant total Armycourse length will be 642 hours, the Navy courselength will be 1,120 hours. Within each syllabus, 449hours of instruction will be presented in a jointformat.5(p7)

RESOURCE REQUIREMENTS ANALYSIS

The Preventive Medicine Resources RequiredAnalysis was conducted at the AMEDDC&S, August14-16, 2007. The following were the areas of focusduring the sessions:

Manpower analysts identified instructor, average dailystudent load, and student man-year requirements. Therepresentatives reviewed the course model datadeveloped during the Detailed Analysis Group. Thegroup consensus was a consolidated lecture ratio of2:56 (later amended to 2:61). The discussion focusedon the requirement to divide students into groups witha ratio of 1 instructor for every 6 students during themajority of the consolidated laboratory exercises.Service instructors expressed concerns that instructor/student ratios should be preserved. This concern wasdue to the fact that proper instructor/student ratios

were not initially being maintained during overlappingiterations (overlapping iterations drive requirements to21 instructors, without regard to service). Themanpower cost model initially authorized 17instructors (8 Navy, 9 Army). After further analysis,21 instructors (10 Navy, 11 Army) were authorized,thereby resolving concerns about instructor/studentratios. The initial class size was 56 students (36 Army,20 Navy) with 6 projected class iterations.9 Thesenumbers were revised at the design charrette* for theMedical Education and Training Campus buildings 3and 4, raising class size to 61 students (35Army, 26Navy).

Facilities analysts did an in-depth review to identify allrequirements needed to support training. The analystsused FY 2010 year of execution data and servicestudent numbers for all studies. The analysts, inconjunction with service subject matter experts,determined the consolidated and integrated enlistedpreventive medicine instructional facility would have 4laboratories: microbiology/water analysis (Figure 1),industrial hygiene (Figure 2), medical entomology,which would have an associated small multifunctionlab primarily used by the Navy for clinical aspects ofpublic health (Figure 3). In addition, 4 student lectureclassrooms were designed: one for 61 students in ajoint lecture environment, one for 36 students forArmy specific lecture, and 2 classrooms, each seating26 students for Navy specific lectures.

Resources Required Analysis attendees met with theMedical Education and Training Campus/TransitionIntegration Office (METC/TIO) staff to determineequipment requirements, manpower overhead, and theconcept of operations.

The METC/TIO staff also discussed academicconcerns regarding curriculum development, clinicalsites, and accreditation and certification issues.9(p3)

The Navy representatives expressed several concernsrelative to academics and associated accreditation andcertification. For example, the Program Director mustbe a credentialed (grade O5) Environmental HealthOfficer or Army equivalent Environmental Science

*A final, intensive effort to finish a project before a dead-line.Source: Random House Unabridged Dictionary. New York, NY:Random House, Inc; 2006.

Figure 1. Planned preventive medicine microbiology/water analysis laboratory classroom (61 students,1,661 sq ft) for the consolidated and integrated enlistedpreventive medicine instructional facility at Fort SamHouston, Texas.

The Army Preventive Medicine Specialist in theMedical Education and Training Campus Era



Figure 3. Planned preventive medicine medical entomology laboratory classroom (2,548 sq ft)for the consolidated and integrated enlisted preventive medicine instructional facility at FortSam Houston, Texas.

Figure 2. Planned preventive medicine industrial hygiene laboratory classroom (2,905 sq ft) forthe consolidated and integrated enlisted preventive medicine instructional facility at Fort SamHouston, Texas.


and Engineering Officer (ESEO) to meet requirementswhich allow Navy students to sit for certificationexams. As previously discussed, Navy PMTs arecurrently eligible for the National EnvironmentalHealth Association professional certification* as aCertified Environmental Health Technician (CEHT).The Navy PMTs take the CEHT examination at theend of the entire curriculum (including clinicaltraining) prior to transfer to their next duty station.Navy PMTs are eligible for the examination based onthe current Navy curriculum which allows the studentto earn 48 to 60 semester hours of credit towards theBachelor of Science (Health Sciences) degreecompletion program at selected colleges anduniversities.10 Since the Army requires credentialcertification of all field grade ESEOs,11 the Navyagreed to the rotation of the directorship of thisprogram.

DESIGN CHARRETTE

After the Resources Required Analysis, the METCleadership team held a series of design charrettes,which included AMEDDC&S preventive medicinerepresentatives, to address each of the MedicalInstructional Facilities (MIF) (preventive medicine isassigned to MIF-4). It is within this process thatdetailed requirements for laboratories, classrooms,white boards, smart podiums, etc, were documented.The results of this effort yielded a formal request forproposal, which, at the time this article was written,had not been released.

CONCLUSION

The US Army has invested heavily in the future ofpreventive medicine. They have driven detailedanalyses of time, programs of instruction, andequipment and facilities required to produce theSoldiers of tomorrow. Make no mistake, the future ofthe Army Preventive Medicine Specialist is bright.From Initial Entry Training/Advanced IndividualTraining, our Soldiers will have the benefit of workingand learning in a joint services environment. While theinitiative for a unified medical command was notadopted because of the significant differences inorganization, responsibilities, and operations of US AirForce preventive medicine assets relative to the Armyand Navy, the Services have been directed by theDeputy Secretary of Defense into a “new governance

plan.”12 This plan focuses on medical research,medical education and training, health care delivery inmajor markets, and shared support services. While thisdoes not include battlefield health care, the primaryand most crucial reason for considering a unifiedmedical command, the Army Preventive MedicineSpecialist and Navy Preventive Medicine Technicianwill reap the benefits of BRAC 2005 Recommendation172.3 This is because both Army and Navy preventivemedicine personnel serve in infantry units—the Armybrigade combat team and the Navy in the MarineCorps infantry battalion. Currently, in Iraq andAfghanistan there are countless examples of Army andNavy preventive medicine units working bothinteroperably and interchangeably, furthering DoD’sForce Health Protection requirements. By starting thisorientation of our Soldiers at the earliest point in theirArmy career, the Army and Navy will only improvethis requirement.

REFERENCES

1. Gilmore GJ. President sends BRAC commissionreport to Congress [Dept of Defense informationwebsite]. September 16, 2005. Available at: http://www.defenselink.mil/news/newsarticle.aspx?id=17278. Accessed January 17, 2008.

2. Miles D. BRAC deadline expires; DoD to beginclosures, realignments [Dept of Defense informationwebsite]. November 9, 2008. Available at: http://www.defenselink.mil/news/newsarticle.aspx?id=18352. Accessed January 17, 2008.

3. US Dept of Defense. 2005 Base Closure andRealignment Commission Report. Vol 1. Arlington,Virginia: Defense Base Closure and RealignmentCommission; September 8, 2005:262. Available at:http://www.brac.gov/docs/final/Volume1BRACReport.pdf. Accessed April 17, 2008.

4. Medical Joint Cross Service Group. Annex. X:Medical Joint Cross Service Group Report for BRAC2005. Arlington, Virginia: Defense Base Closure andRealignment Commission, Medical Joint CrossService Group; May 9, 2005:43. Available at: http://www.defenselink.mil/brac/pdf/VolX_Medical-o.pdf.Accessed January 17, 2008.

5. Health Care Interservice Training Office. DetailedAnalysis Group Report: 6-8 March 2007. San Diego,California; Naval School of Health Sciences; 2007:3.

6. Department of Defense Directive 6490.02E;Comprehensive Health Surveillance. Washington,DC: US Dept of Defense; October 21, 2004.

The Army Preventive Medicine Specialist in theMedical Education and Training Campus Era

*Information available at: http://www.neha.org/credential/



7. Department of Defense Instruction 6490.03;Deployment Health. Washington, DC: US Dept ofDefense; August 11, 2006.

8. Office of the Chairman, Joint Chiefs of Staff.Memorandum MCM 0028-07, Procedures forDeployment Health Surveillance. Washington DC:US Dept of Defense; November 2, 2007. Availableat: http://amsa.army.mil/Documents/JCS_PDFs/MCM-0028-07.pdf.

9. Health Care Interservice Training Office. ResourceRequirements Analysis Summary Report: June-September 2007. Fort Sam Houston, Texas; US ArmyMedical Dept Center and School; 2007:3.

10. Health Care Interservice Training Office. PreventiveMedicine Specialist: Preventive MedicineTechnician: Resource Requirements Analysis Report:14-16 August 2007. Fort Sam Houston, Texas; USArmy Medical Dept Center and School; 2007:4.

11. Army Pamphlet 600-4; Army Medical DepartmentOfficer Development and Career Management.Washington, DC: US Dept of the Army; June 27,2007:78.

12. Philpott T. Rejected medical command [Military.comwebsite]. December 16, 2006. Available at: http://www.military.com/features/0,15240,120543,00.html.Accessed January 27, 2008.

AUTHORS

LTC Kilian is Chief, Environmental Quality Branch,and Program Manager for 68S10, Department ofPreventive Health Services, AMEDDC&S, Fort SamHouston, Texas.

SFC Patton is the Noncommissioned Officer in Charge,Environmental Quality Branch, and Class Advisor for68S10, Department of Preventive Health Services,AMEDDC&S, Fort Sam Houston, Texas.

At the time this article was written, HMCS Adams wasthe Service Lead, Preventive Medicine TechnicianCourse, Naval School of Health Sciences, San Diego,California. He is currently the Command Master Chief,USS Reuben James (FFG-57).

The US Army Medical Department Center and School, Fort Sam Houston, Texas


INTRODUCTION

Arthropod-borne pathogens that cause diseases, suchas malaria, yellow fever, and dengue, are major healththreats to the military. For example, losses to malariaand other preventable diseases among Allied forcesoperating in the China-Burma-India theater duringWorld War II far exceeded the number of casualtiesinflicted by enemy action.1 Malaria was second only tocombat injury as the reason for hospitalization amongAmerican troops in Vietnam, and the number onereason for troops deployed to Somalia.2 A significantproportion of Joint Task Force personnel inserted intoLiberia in August 2003 (80 out of 290 who had beenashore) experienced symptoms of malaria.3 Infectedtroops returning to the United States increase the rateof imported malaria.4

Anopheles mosquito species are solely responsible forglobal malaria cases. Over 450 species of Anophelesare known, but only a fraction are malaria vectors.More precise information on the actual and potentialgeographic distribution of the species responsible formalaria could assist a host of health-related actions,including predeployment counselling for prophylaxis;the choice of health messages during deployment;

decisions as to the locations of refugee camps,hospitals, and bases; postdeployment evaluation ofhealth risk exposures; selection of the type and extentof vector control; the choice of vector identificationtools; identification of the likely vector for a region;and management or quarantine of invasive vector andparasite species.

Recently, computer programs have become availablethat combine climate information with data on whereorganisms have been collected to produce maps of thepotential distribution of these organisms.5,6 A varietyof mosquito species have been modeled in this way.7,8

The output from these models, usually the suitabilityfor occurrence of a particular species, can be extendedto a resolution of one km2 or less.

The zone where humans, parasites and vectors co-occur constitutes a geographic area of malaria risk thatwe dub the “mal-area” (see Figure 1). The mal-areacan be regarded as the ecological niche or potentialspatial extent of this disease.9 A subset of theecological niche is the mal-area of currenttransmission, which expands and contracts accordingto the level of mosquito survival and abundance,human-vector contact, and case detection and

Malaria Risk Assessment for theRepublic of Korea Based onModels of Mosquito Distribution

Desmond H. Foley, PhDCOL (Ret) Terry A. Klein, MS, USA

Heung Chul Kim, PhDRichard C. Wilkerson, PhD

Leopoldo M. Rueda, PhD

ABSTRACT

Data on climate, environment, and adult and larval mosquito collection sites throughout the Republic of Korea(ROK) were used to model the potential distribution of the 8 anopheline species known to occur there. Thesemodels were overlaid on predicted areas of malaria suitability to better define the distribution of malaria risk inthe ROK. The concept of the “mal-area”— an area of co-occurrence of humans, parasites and vectors, wheremalaria transmission is possible—is explained. Quantification of the mal-area in the vicinity of 5 militaryinstallations in the north of the country suggested that they had very different malaria risks, depending on whatthe vector species were, and the method of calculation. An online mal-area calculator for malaria risk assessment(currently under development) is discussed.


treatment, among a myriad of other factors. Becausethe Plasmodium parasite is normally dependent on ahuman or mosquito host, the mal-area shouldapproximate the spatial extent of the parasite. Thephenomenon of “anophelism without malaria”describes the area where vectors and humans, but notparasites, co-occur, eg, many populated parts of theUnited States have malaria vectors but the disease waseradicated there.

Until recently, detailed intelligence on the distributionof vectors was not available for malaria risk models.The Malaria Atlas Project10 (MAP) models the limitsof actual malaria transmission using information oninternational travel-health guidelines and estimates ofvector occurrence, from altitude and degree ofurbanization data.11

Fine-tuning such maps of global malaria suitability byincorporating detailed mosquito species distributionmodels could provide a clearer picture of areas ofheightened malaria risk. The resulting mal-area extentcould be used as a simple index to compare malariarisk between locations of interest (Figure 1).Specifically, mal-area mapping could improve forcehealth protection in areas of operation such as theRepublic of Korea (ROK) that have a history ofmalaria transmission.

Prior to the 1950s, Plasmodium vivax malaria wasendemic and widespread in the ROK,12 suggesting thatthe potential mal-area is extensive in that country.Malaria was eradicated in the 1970s but reemerged in1993 and reached a peak of 4142 cases in 2000 beforefalling to 774 cases in 2004.13 Most malaria casesappear to have been contracted near the DemilitarizedZone (DMZ) that separates North and South Korea.13

This is reflected in the northerly location of the area ofcurrent malaria suitability, as determined by the MAPmodels (see Figure 2). The anopheline fauna of SouthKorea (ie, the ROK) is relatively well resolvedtaxonomically,14-16 and ongoing mosquito surveillancemakes this country an ideal location to test the mal-area approach to assessing malaria risk. Theanopheline fauna of the ROK includes 8 species:

Anopheles sinensis sensu stricto (s.s.) WiedemannAn. pullus M. Yamada (=An. yatsushiroensis)An. lesteri Baisas & Hu (=An. anthropophagus)An. sineroides S. YamadaAn. kleini RuedaAn. belenrae Rueda

An. lindesayi japonicus S. Yamada

An. koreicus S. Yamada & Watanabe

These species are not all identifiable based onmorphology, but a polymerase chain reaction (PCR)technique has been developed for speciesidentification.15 Historically, An. sinensis wasconsidered the primary vector. However, the discoveryof additional species and results from field andlaboratory parasite studies have combined to point toAn. kleini, An. pullus, and An. sinensis as the likelyvectors around the DMZ.13 Logically, since furthermosquito and parasite sampling is required, all speciescould be regarded as potential vectors.

Figure 1. Illustration of the concept of the mal-area as itapplies to malaria risk assessment in geographic space.Presence/absence of humans (H), areas of suitability forPlasmodium species (P), and predicted distribution ofmalaria vectors (V) are shown, as well as the mal-area(VPH); the area of overlap where malaria transmission ispossible. Histogram shows the percentage of the sampledarea that these parameters cover. The value for VPHcould be used as a simplified index of malaria risk tocompare different areas.


We used climate and adult and larval mosquitocollection data from sites throughout the ROK tomodel the distribution of all 8 anopheline species. Tobetter understand the distribution of malaria risk in theROK, especially around military installations in thenorth of the country, the resulting models of potentialspecies distributions were compared with areas ofmalaria suitability. An online mal-area calculator formalaria risk assessment that isunder development is discussedlater in this article.

MATERIALS ANDMETHODS

Adult mosquito surveillancewas conducted at selected USmilitary installations using NewJersey light traps (John W.Hock Co, Gainesville, FL) andM o s q u i t o M a g n e t s ®

(Woodstream Corporation,Lititz, PA) (Figure 3), andlarval collections were madethroughout the ROK. Adultsand larvae were identified tospecies by comparison of DNAproducts produced by PCR.15

We used the Genetic Algorithm for Rule-set Prediction(GARP)5,17 and a maximum entropy approach, knownas Maxent,6,18 for distribution modelling. GARP usesan iterative process of rule selection, evaluation,testing, and incorporation or rejection. The geneticalgorithm in GARP allows the rules to “evolve” tomaximize predictive accuracy. A rule is selected and isapplied to half the points (training data) and modelsassessed with the other half of the points (testing data).The change in predictivity between iterations is used toevaluate whether a particular rule should beincorporated into the model. Maxent is based on theidea that the best explanation for unknown phenomenawill maximize the entropy of the probabilitydistribution, subject to the constraint of theenvironmental conditions where species have beendetected. Output was predicted probability of presence.The methodology and results of this modelling will bereported in greater detail in a forthcoming paper.

We obtained

altitude and a selection of climate grid layers for1980 through 1990 from Worldclim,19

five layers summarizing aspects of topography andlandform (topographic index, slope, aspect, flowdirection, and flow accumulation) from the USGeological Survey’s HYDRO-1K ElevationDerivative Database,20

data layers summarizing the “greenness index”—termed the Normalized Difference Vegetation

Index21—from the AdvancedV e r y H i g h R e s o l u t i o nRadiometer satellite datapresenting percentage tree coverfor 1992-1993,

thirteen classes of land-use/land-cover from the GlobalLand Cover Facility,22

soil taxonomy suborders ofthe world from the USDepartment of AgricultureNational Soils ConservationService,23 and

data on areas equipped forirrigation from the Aquastat siteof the Food and AgricultureOrganization of the UnitedNations.24

Figure 2. Locations of mosquito collection points in theROK used in species distribution modelling. Also depictedis the extent of the area predicted active for malaria.(Data derived from the Malaria Atlas Project.10 Data fromthe boxed area was used for mal-area calculations.

Figure 3. The Mosquito Magnet uses propaneto produce CO2 and heat to attract insectvectors which are caught in the vacuum anddeposited in the collection bag.

Malaria Risk Assessment for the Republic of KoreaBased on Models of Mosquito Distribution



In all, 79 one-km2 environmental data layers wereavailable, which we reduced to 15 by principalcomponents analysis (PCA) in Minitab 15.1.1.0

(Minitab Inc, State College PA) prior to mosquitodistribution modelling. The 15 PC layers explainedmore than 95% of the overall variation in the 79

environmental parameters. We imported datainto ArcView 3.3 (ESRI, Redlands, CA) forimage analysis.

The current spatial limits of P. vivax in theROK were taken from the MAP website10 andresampled for one-km2 resolution to matchthat of the mosquito distribution models (seeFigure 2). We assumed that human populationdensity throughout the areas of interest wassufficient for malaria transmission. We applieda 10-km radius buffer around 5 selected USmilitary installations in the northeast of theROK. Using ArcView 3.3, we conducted mapqueries for 3 scenarios for possible areas ofcoincidence of vectors and malaria within thebuffers, where false = 0 and true = 1. We alsoconducted a map calculation for a fourthscenario where no coincidence of vectors andmalaria = 0, one vector species coinciding withmalaria = 1, two species coinciding = 2, andthree species coinciding with malaria = 3. Inscenario 1, only one species, An. sinensis, isconsidered a vector, as had been assumed byworkers in the past. Scenario 2 assumes thatany of the 8 anopheline species occurring inthe ROK can transmit malaria if they co-occurwith the spatial limits of parasites. This is themost conservative scenario. Scenario 3assumes An. kleini, An. pullus, and An.sinensis are vectors, as has been suggested inthe literature.13 In this scenario the co-occurrence of any or all of these species withthe malaria suitable area is scored as true (= 1)for the purposes of the mal-area calculation.Scenario 4 assumes An. kleini, An. pullus, andAn. sinensis are vectors, but that the riskincreases if more than one species co-occurswith the malaria suitable area. These specieswere equally weighted, as definitiveinformation on their relative vectorialimportance is lacking. The total number ofone-km2 pixels scored true for the first 3scenarios, and the sum of values for thesepixels for the fourth scenario were calculatedfor the buffered areas surrounding the 5installations.

Figure 4. Examples of Maxent models of the potential distributionfor 2 anopheline species in the ROK, based on mosquitocollection data and environmental data layers. Darker shadingindicates greater predicted suitability of that area for theoccurrence of that species.


RESULTS

Mosquitoes were identified to species from a total of174 collection locations in the ROK from collectionsfrom 1998 through 2006 (see Figure 2). Some of thesedata were reported previously.25 Distribution modelsrevealed that An. sinensis, An. kleini, An. pullus, andAn. belenrae were predicted to occur widely, whereasAn. lesteri is predicted to occur only in northwest areasof the ROK (Figure 4). Examples of output fromMaxent models for An. kleini and An. lesteri arepresented in Figure 4. Collection data and distributionmaps will be available from the MosquitoMapwebsite* and in a future publication. All species arepredicted to occur in the north of the ROK wheremalaria has been most common since it firstreappeared in 1993.

Mal-area calculations for the 4 scenarios are shown inFigure 5. In all scenarios, Camp Humphreys has nomalaria transmission risk due to it falling outside thepredicted spatial limits of malaria as given on theMAP website.10 Comparison of the mal-area scores(Figure 6) reveals that Camp Humphreys andKwangsa-ri have the lowest values. The scores forscenario 4 are higher than for the other scenarios,

reflecting the cumulative effect of vector species’occurrences on malaria risk. In these examples, therank of the malaria risk of the 5 installations does notchange markedly with the different scenarios, exceptthat Colbern has a higher score for the An. sinensis-only scenario.

DISCUSSION

Arthropod-borne infectious diseases are a major healththreat to our combat troops. We cannot afford toignore this health threat nor repeat the mistakes ofprevious conflicts where many Soldiers weredebilitated or killed by preventable infectious diseases.Knowledge of the identity and occurrence of the majorvectors is a prime requirement to determine the threatposed by vector-borne diseases. Predicting where thevectors are likely to be found could be a valuableaddition to health risk assessment and disease controlstrategies.

As standardized and accessible techniques formodelling the distribution of disease vectors are recentdevelopments, the approach given here is new.Application of models of vector distribution to diseaserisk assessment is a logical next step. We have shownthat a simple index of the area where disease*http://www.mosquitomap.org

Figure 5. Four scenarios of the extent of the mal-area for malaria within 10 km of 5 US military installations in theROK (one-km2 pixel resolution), based on vector distribution models and the areas predicted suitable for malaria, fromthe Malaria Atlas Project.10 Darker areas indicate greater risk of malaria.Legend:

A. Anopheles sinensis is the only vector.B. Any of the 8 Anopheles species known from the ROK are present.C. Any of 3 species (An. kleini, An. sinensis and An. pullus) is present.




transmission is possible, the mal-area, can be used toassess disease risk for a 10 km radius buffer aroundUS military installations in the ROK. Although anysize area can be considered, a 10-km buffer isappropriate to calculate the health risk arising from thelocal environment, or the amount of vector controlneeded within a barrier zone around these points.

We have shown that the method of calculating themal-area is an important variable. Identification of thevector species, and the weight attached to these speciesin terms of vectorial importance is also critical.However, the accuracy, scale, and precision of modelsof vector and parasite distribution is of fundamentalimportance. It should be noted that little information isavailable for malaria in North Korea11 and so themalarious area may extend further north than shownhere. The World Health Organization reported that amalaria epidemic occurred in North Korea shortly afterthe first case of malaria reemerged along the DMZ in

1993, suggesting a parallel outbreak occurred in bothcountries.26 The mal-area calculations shown here donot yet take into account seasonality, use of insecticidebed nets, human movement, socio-economic level, ormany other variables that modify the prevalence andincidence of malaria. In addition, vector distributionmodels predict general habitat suitability, but factorsnot included in these models include historical,physical, climatological, and biotic constraints thatmay play a role in limiting potential distribution.Evaluating and improving vector model accuracy is anongoing task, but better models can be easilyincorporated as they become available.

Despite the simplified assumptions of the mal-areamethod of risk assessment shown here, the approach ispotentially very quick and can be used for any area ofinterest in the world, even where medical intelligenceis sketchy. One can see the location of the mal-areawithin the area of interest, or the mal-area can be

Figure 6. Mal-area calculations in number of one-km2 pixels for malaria within 10 km of 5 US military installations in theROK, based on vector distribution models and the areas predicted suitable for malaria, from the Malaria Atlas Project.


reduced to a single figure to compare risk betweenareas. In the absence of other intelligence, the mal-areaapproach has potential as a first approximation of risk.Alternatively, vector and mal-area maps can be used asbase layers in more complex epidemiological GISdisease risk models. A generic mal-area tool couldconceivably be used to measure any risk factor,including other vector-borne diseases, where spatialmodels of the risk components are available. Such atool would have great value for medical intelligenceestimates, particularly when forces are deployed tohostile locations for the first time.

We are constructing high resolution maps of potentialgeographical distribution of a selection of mosquitovectors of disease which will soon be available via theMosquitoMap website, an online clearinghouse forgeoreferenced mosquito collection records, and speciesdistribution models derived from those records.MosquitoMap uses ArcGIS Server 9.2 to enable thequery and mapping of georeferenced mosquitocollection records as points or country-levelaggregations. Data come from records held bymuseums, scientific literature, and private collections.Currently there are 65,000 records, mainly forAustralasia and the Neotropics.

An application within MosquitoMap, the mal-areacalculator, is designed to provide a fast, easy, andintuitive interface for rapidly assessing relative malariarisk. The intention is for the user to define a location orarea anywhere on the face of the earth and thecalculator combines models of disease distributionwith predicted distribution of major disease vectors.Based on the location or area defined, an HTML and/or PDF chart will be rendered that graphs statistics forgrid layers of various combinations of the VPHvariables. These statistics will consist of thepercentage of cells that contain a certain value for theuser defined area. MosquitoMap and the mal-areacalculator rely on distribution models for all vectorspecies, but these are currently lacking. However,these applications provide a framework to host andanalyze future vector and disease models as theybecome available.

ACKNOWLEDGEMENT

Funding for this project was provided by theDepartment of Defense Global Emerging InfectionsSurveillance and Response System, Silver Spring, MD

(project No. G00018_08_WR). We thank A.Townsend Peterson for advice regarding distributionmodelling. We thank LCDR Jean-Paul Chretien foradvice and support. This research was performedunder a Memorandum of Understanding between theWalter Reed Army Institute of Research and theSmithsonian Institution, with institutional supportprovided by both organizations.

REFERENCES

1. Stone JH, ed. Crisis Fleeting. Washington, DC:Office of The Surgeon General, US Dept of theArmy; 1969.

2. Malaria Foundation International. FAQs. Availableat: http://www.malaria.org/travelhealth.html.

3. Smith AM, Hooper C. The mosquito can be moredangerous than the mortar round. The obligations ofcommand. Nav War Coll Rev. 2005;58(1):77-87.Available at: http://www.nwc.navy.mil/press/review/documents/NWCRW05.pdf.

4. Barrett O. Malaria: epidemiology. In: Ognibene AJ,Barrett O, eds. Internal Medicine in Vietnam. VolumeII, General Medicine and Infectious Diseases.Washington, DC: Office of The Surgeon General, USDept of the Army; 1982:279-291.

5. Pereira RS. Desktop GARP. 2002. Available at:http://www.lifemapper.org/desktopgarp/.

6. Phillips SJ. Maxent software for species habitatmodeling, ver. 2.2.0. 2006. Available at: http://www.cs.princeton.edu/~shapire/maxent/.

7. Levine RS, Peterson AT, Benedict MQ. Geographicand ecologic distributions of the Anopheles gambiaeComplex predicted using a genetic algorithm. Am JTrop Med Hyg. 2004;70:105–109.

8. Moffett A, Shackelford N, Sarkar S. Malaria inAfrica: vector species’ niche models and relative riskmaps. PloS ONE. 2007;2(9):e824. doi:10.1371/journal.pone.0000824.

9. Peterson AT. Ecological niche modelling andunderstanding the geography of disease transmission.Vet Italiana. 2007;43:393-400.

10. Malaria Atlas Project website. Available at: http://www.map.ox.ac.uk/MAP_overview.html.

11. Guerra CA, Snow RW, Hay SI. Defining the globalspatial limits of malaria transmission. Advances inParasitol. 2006;62:157-179.

12. Ree H-IL. Unstable vivax malaria in Korea. Korean JParasitol. 2000;38:119-138.




13. Lee W-J, Klein TA, Kim H-C, Choi Y-M, Yoon S-H,Chang K-S, Chong S-T, Lee I-Y, Jones JW, JacobsJS, Sattabongkot J, Park J-S. Anopheles kleini,Anopheles pullus, and Anopheles sinensis: potentialvectors of Plasmodium vivax in the Republic ofKorea. J Med Entomol. 2007;44(6):1086-1090.

14. Wilkerson RC, Li C, Rueda LM, Kim HC, Klein TA,Song GH, Strickman D. Molecular confirmation ofAnopheles (Anopheles) lesteri from the Republic ofSouth Korea and its genetic identity with An. (Ano.)anthropophagus from China (Diptera: Culicidae).Zootaxa. 2003;378:1-14.

15. Li C, Lee JS, Groebner JL, Kim H-C, Klein TA,O’Guinn ML, Wilkerson RC. A newly recognizedspecies in the Anopheles Hyrcanus Group andmolecular identification of related species from theRepublic of South Korea (Diptera: Culicidae).Zootaxa. 2005;939:1-8.

16. Rueda LM. Two new species of Anopheles(Anopheles) Hyrcanus Group (Diptera: Culicidae)from the Republic of South Korea. Zootaxa.2005;941:1-26.

17. Stockwell DRB, Noble IR. Induction of sets of rulesfrom animal distribution data: a robust andinformative method of analysis. Math Comput Simul.1992;33:385-390.

18. Phillips SJ, Anderson RP, Schapire RE. Maximumentropy modeling of species geographic distributions.Ecol. Modell. 2006;190:231-259.

19. Hijmans RJ, Cameron S, Parra J. WorldClim [data-base online]. Available at http://www.worldclim.org/.

20. HYDRO1k home page. US Geological Surveywebsite. Available at: http://edc.usgs.gov/products/elevation/gtopo30/hydro/.

21. MODIS Normalized Difference Vegetation Indexpage. University of Maryland Global Land CoverFacility website. Available at: http://glcf.umiacs.umd.edu/data/ndvi/.

22. Land Cover Classification page. University of Mary-land Global Land Cover Facility website. Availableat: http://glcf.umiacs.umd.edu/data/landcover/.

23. Global Soils Region Map. US Dept of AgricultureNational Resources Conservation Service website.Available at: http://soils.usda.gov/use/worldsoils/mapindex/order.html.

24. AQUASTAT resources page. Food and AgricultureOrganization of the United Nations website.Available at: http://www.fao.org/nr/water/aquastat/main/index.stm.

25. Rueda LM, Kim H-C, Klein TA, Pecor JE, Li C,Sithiprasasna R, Debboun M, Wilkerson RC.Distribution and larval habitat characteristics ofAnopheles Hyrcanus Group and related mosquitospecies (Diptera: Culicidae) in South Korea. J VectorEcol. 2006;31:198-205.

26. Han ET, Lee DH, Park KD, Seok WS, Kim YS,Tsuboi T, Shin EH, Chai JY. Reemerging vivaxmalaria: changing patterns of annual incidence andcontrol programs in the Republic of Korea. Korean JParasitol. 2006;44:285-294.

AUTHORS

Dr Foley is a Research Entomologist at the Walter Reed Biosystematics Unit of the Division of Entomology, WalterReed Army Institute of Research, based at the Smithsonian Institution Museum Support Center, Suitland, Maryland.

COL (Ret) Klein is a consultant with Force Health Protection, 18th Medical Command, Unit 15281, Yongsan Garrison,Seoul, Republic of Korea.

Dr Kim is a Research Entomologist with the 5th Medical Detachment, 168th Medical Battalion (AS), 18th MedicalCommand, Unit 15247, Yongsan Garrison, Seoul, Republic of Korea.

Dr Wilkerson is a Research Entomologist and Manager at the Walter Reed Biosystematics Unit of the Division ofEntomology, Walter Reed Army Institute of Research, based at the Smithsonian Institution Museum Support Center,Suitland, Maryland.

Dr Rueda is a Research Entomologist at the Walter Reed Biosystematics Unit of the Division of Entomology, WalterReed Army Institute of Research, based at the Smithsonian Institution Museum Support Center, Suitland, Maryland.


ABSTRACT

The US Air Force has had a long history of aerialapplications of pesticides to fulfill a variety ofmissions, the most important being the protection oftroops through the minimization of arthropod vectorscapable of disease transmission. Beginning in WorldWar II, aerial application of pesticides by the militaryhas effectively controlled vector and nuisance pestpopulations in a variety of environments. Currently,the military aerial spray capability resides in the USAir Force Reserve (USAFR), which operates andmaintains C-130 airplanes capable of a variety ofmissions, including ultra low volume applications forvector and nuisance pests, as well as higher volumeaerial applications of herbicides and oil-spilldispersants. The USAFR aerial spray assets are theonly such fixed-wing aerial spray assets within theDepartment of Defense. In addition to troopprotection, the USAFR Aerial Spray Unit hasparticipated in a number of humanitarian/reliefmissions, most recently in the response to the 2005Hurricanes Katrina and Rita, which heavily damagedthe Gulf Coasts of Louisiana, Mississippi, and Texas.This article provides historical background on the AirForce Aerial Spray Unit and describes the operationsin Louisiana in the aftermath of Hurricane Katrina.

INTRODUCTION

Human health has long been at risk from arthropod-borne diseases. Malaria, dengue, West Nile virus, andothers continue to cause human health problems andcreate media attention. Military entomologists areacutely aware of the disease threat to deployed troopsfrom insect pests, and have remained an integral partof the Department of Defense (DoD) since they wereemployed with excellent results to combat malaria inthe South Pacific during World War II.1 In thatconflict, military entomologists quickly developedeffective strategies to control mosquitoes and maintain

troop health. One such method was the application ofinsecticides from aircraft to areas with high mosquitoactivity. Aerial applications of pesticides are aneffective way of rapidly reducing numbers of potentialinsect vectors across large areas and in a relativelyshort period of time.2-5 Unlike truck-mounted sprayunits or backpack sprayers, aircraft can accessdeveloped and undeveloped areas which are prone toarthropod outbreaks.

The Air Force has the mission to provide a fixed-wing,large-area, aerial pesticide application capability tocontrol disease vectors, pest organisms, andundesirable/invasive vegetation, as well as treat oilspills in combat areas, on DoD installations, or inresponse to declared emergencies. In addition, DoDrequires the Air Force to provide training to air crewsand ground support personnel in the principles andpractices of aerial pesticide application.

The Air Force Aerial Spray Unit (AFASU) traces itshistory back to early aerial applications of DDT duringthe later stages of World War II. After the end of thewar, the Special DDT Flight was created in 1946, butwas soon transformed to the Special Aerial SprayFlight (SASF) in 1947 when the Air Force became aseparate armed service.6 Eventually, as US militaryoperations in Vietnam were reduced in the early1970s, active duty Air Force assets were moved toreserve status, including spray planes returning fromOperation Ranch Hand defoliation flights in Vietnam.7

After more than 25 years at Langley Air Force Base,Virginia, the SASF was transferred from the active AirForce to the Air Force Reserve in 1973. Prior to thistransfer, the SASF had sprayed for mosquitoes,Japanese beetles, and fire ants in various locations atthe request of the Army, Navy, and other federalagencies. The move to the Air Force Reserve resultedin a change of location and designation. Relocated toRickenbacker Air Force Base, Ohio, the unit was

The US Air Force Aerial Spray Unit:A History of Large Area Disease VectorControl Operations, WWII Through Katrina

Maj Mark Breidenbaugh, BSC, USAFRMaj Karl Haagsma, BSC, USAFR


referred to as the Spray Branch of the 907th TacticalAirlift Wing. In 1986, the Spray Branch began totransition from C-123 airplanes to C-130A airplanesand developed the modular aerial spray system for usein C-130E and H airplanes. The aerial spray missionwas assigned to the 910th Airlift Wing at theYoungstown Air Reserve Station, Ohio, in 1991.Nonmilitary emergency aerial spray responses (and thetargeted health threat) by Air Force aerial spray assetsas part of the Air Force Reserve are shown in Table 1.

The AFASU trains for a primary wartime mission ofprotecting deployed troops from arthropod-borneillness by participating in ongoing mosquito controlprograms at different locations throughout the UnitedStates. By training in various geographic regions, theAFASU gains experience controlling different vectorand nuisance species under diverse geographical andenvironmental conditions. The same measures areemployed for herbicide applications. Some missionsare designed for soil sterilization, such as at the UtahTest and Training Range, where large targets need toremain free of vegetation so that unexploded ordinancecan be safely recovered. Other herbicide missionsconcentrate on habitat restoration, by lowering thedominance of invasive plant species, allowing nativeplants to recover and lowering the threat of wildfires.The AFASU has been involved with prairie restorationon the Saylor Creek Range, Idaho, combating the

growth of cheatgrass (Bromus tectorum L.), and atSmoky Hill Air National Guard Range, Kansas, for thecontrol of musk thistle (Carduus nutans L.). Table 2lists the AFASU’s current standing domesticoperational commitments and the dates of inceptionfor each.

As mentioned earlier, a modular aerial spray system(MASS) was developed for use with the C-130Hairplane. The MASS, which has a maximum 2,000-

gallon capacity for liquid materials, can berolled on or off the airplane in approximatelyone-half hour. Functional in a variety ofconfigurations, the MASS is useful for suchapplications as ultra low volume adultmosquito sprays (adulticiding), mosquitoliquid larvicide sprays, herbicide applications,and oil dispersants for emergency cleanup ofoil spills.

Ultra low volume sprays create an aerosolcloud of small discrete droplets that driftthrough the air. This type of application isreferred to as a space spray since the goal is todrift droplets through a particular spaceresulting in contact with flying insects.5 Forthis reason, the flight period of the target pestsis one of the most important planning factorsfor missions using the ultra low volumeconfiguration to control mosquitoes andnuisance flies.8 Current methodologies forAFASU mosquito adulticiding use the MASSwith booms placed through the fuselage doors.Those booms are fitted with flat fan nozzles

positioned perpendicular to the slipstream of theaircraft for maximum shear and atomization of thesprayed liquid. This is especially important since thediameter of a droplet that effectively adheres to amosquito is 10 µm to 25 µm.9

In contrast to space spray applications, depositionspray missions produce large drops which are intendedto drop quickly onto a surface (eg, mosquito larvicideor herbicide application).

HURRICANES AND MOSQUITOES

In response to requests from state public healthagencies, the AFASU has been tasked to controlmosquitoes threatening human health or creating anunacceptable nuisance level in the aftermath ofhurricanes (see Table 1).10 However, following some

Year Location Health Threat Coverage(acres)

1973 Panama Equine encephalitis 37,600

1975 Guam Dengue fever 157,530

1978 Azores Japanese beetles 8,700

1983 Minnesota Equine encephalitis 525,000

1985 Idaho Grasshoppers 718,100

1987 Puerto Rico Dengue fever 177,000

1989 South Carolina Hurricane Hugomosquito control

855,500

1992 Florida Hurricane Andrewmosquito control

279,170

1999 North Carolina,Virginia

Hurricane Floydmosquito control

1,700,000

2005 Louisiana,Texas

Hurricanes Katrina andRita mosquito control

2,880,000

Table 1. Nonmilitary emergency deployments by theAFASU after transition to the US Air Force Reserve.


of these events, federal authorities, unfamiliarwith mosquito biology, have questioned thelocal public health officials’ requests formosquito control, apparently unaware of arelationship between hurricanes and increasedmosquito activity. Since the presence ofmosquitoes following storms may surprisesome, perhaps there is a valid question: dohurricanes create abnormally large mosquitopopulations? And, by extension, do hurricanesincrease the risk of mosquito-borne illnessessuch as encephalitides, dengue, and malaria?

Since mosquito larvae develop in water, it isnot difficult to extrapolate that a significantincrease in potential breeding sites as a resultof flooding from hurricanes would lead to asignificant increase in mosquito populations.It is this premise that leads mosquito controlpersonnel and vector ecologists to anticipateincreased mosquito numbers following majorstorms. Logically, the presence of highdensities of mosquitoes increases the potential fortransmission of mosquito-borne disease. It is, however,important to define parameters for making suchstatements. Accordingly, we must identify themosquito species capable of vectoring disease anddetermine if the pathogen is present in the residentmosquito population or enzootic hosts.

The destructive power of hurricanes creates a scenarioin which mosquito populations are increasing at thesame time many people are displaced or have had theirprimary shelters compromised. Exposure tomosquitoes is increased by the concentration of thosedisplaced by the storm into temporary shelters, and bytheir activities as they search for food, constructionmaterials, medical care, etc. Under such conditions,individuals may face maximum exposure to nuisancemosquito bites and mosquito vectors.

Mason and Cavalie11 analyzed a malaria epidemic inHaiti following Hurricane Flora in 1963, observing anexplosive increase in mosquito breeding brought on byheavy rainfall and extensive flooding. In this case, theresearchers also tied an increased incidence of malariato Hurricane Flora because all disease factors werepresent, including a heavy reservoir of gametocytecarriers, mosquitoes, and an exposed population (eg,people displaced and residual insecticide treatmentsnegated by hurricane damage).

More recently, Gagnon et al12 reviewed the incidenceof malaria in El Niño years—which always includesignificant flooding conditions—in South America andfound a significant relationship between flooding andmalaria epidemics in northern Peru.

By contrast, in Honduras, Hurricane Mitch killed6,546 people and displaced another 1.1 million fromexcessive rainfall and flooding.13 Obviously thispopulation was very exposed as a result of thedisplacement, but Campanella and Tarantini14 foundonly a small increase in malaria cases between timeperiods preceding the arrival of Hurricane Mitch(statistically significant compared to 1997 but not to1998). Likewise, O’Leary et al 15 did not find anincrease in dengue in Federal Emergency ManagementAgency (FEMA) relief workers in Puerto Rico afterHurricane Georges in 1998. These researchers relatethat 82% of the workers reported mosquito bites, butunfortunately they do not comment on the overallmosquito density during the study.

Experts are often questioned by the popular press andin some cases opinions on the hurricane-mosquitodisease issue can differ markedly. For example, theNew Orleans Times-Picayune quoted the StateEpidemiologist of Louisiana as saying that heavyrainfall from hurricane Katrina actually killed adultmosquitoes, washed away larvae, and killed or

Table 2. Current AFASU domestic operational commitments.

Location or Agency Purpose Yearinitiated

Langley Air Force Base, VA Mosquito control 1973

Marine Corps RecruitDepot, Parris Island, SC

Biting midges andmosquito control

1983

Hill Air Force Base, UtahTest and Training Range

Clearing bombingrange undergrowth

1983

US Coast Guard Oil spill dispersants 1992

Smoky Hill Air NationalGuard Range, KS

Musk thistle control 1995

Mountain HomeAir Force Base, ID

Cheat grass control 2000

Grand ForksAir Force Base, ND

Mosquito control 2001

Minot Air Force Base, ND Mosquito control 2005

The US Air Force Aerial Spray Unit:A History of Large Area Disease Vector Control Operations



dispersed the birds that carry West Nile virus.16

Without quoting a source, in 2006 Lauran Neergaardof the Associated Press stated somewhatcontradictorily that “…recent research shows:…Hurricanes don't spur West Nile [virus mosquitovectors]. Instead, heavy rains temporarily flush out thetiny pools where mosquitoes have laid eggs. Yet theCDC [Centers for Disease Control and Prevention]fears that New Orleans and the Gulf Coast are ripe fora surge in West Nile this summer because of the rubbleleft by Hurricane Katrina last year, full of water-collecting crevices that make perfect mosquitobreeding grounds.”17 Other news articles madecontrasting statements. The director of the Universityof Minnesota Center for Infectious Disease Researchand Policy warned that following Hurricane Katrina,rural areas could expect dramatic increases inmosquito numbers within 2 weeks, especially thoseareas where the storm left many pools of stagnantwater.18 Similarly, in October 2005, the HoustonChronicle [online] reports that, according to TexasA&M University entomology professor Jim Olson,floodwater mosquitoes take advantage of a direct hitfrom a storm in unique ways. They are able to hide ingrass and avoid being blown away by wind. But whenthe storm surge hits, they ride it inland like surfers,into new territory. Further, Professor Olson says, “Thehurricane actually concentrates them, it exacerbatesthe problem.”19 In comments to The Rocky MountainNews in September 2005, Dr Janet McAllister of theCDC described the mosquito problem 2 weeks afterHurricane Katrina as having reached “biblicalproportions.”20 However, in the online discussionson the ProMED website, other contributors in thefield suggested the opposite.21

In summarizing the above information, it appearsthat immediately following the landfall of a majorhurricane, the mosquito problem may actuallydisappear or be minimized by intense wind, rainfall,and flooding. However, it is generally agreed thatadditional developmental habitat is created by suchstorms and, depending on environmental factors(temperature, rainfall, contamination, topography,etc), large numbers of vector and/or nuisance bitingmosquitoes can be present in a period as short as 2weeks.22

The American Mosquito Control Association andthe CDC, along with a host of federal, state, andcounty level public health agencies, have worked

diligently to convince FEMA to anticipate majormosquito outbreaks following hurricanes and otherflood producing events and to develop strategicresponses to such events. Developing a dialoguebetween federal and state public health agencies wasone reason that the vector control aspects of theresponse to Hurricane Katrina were quick anddecisive.

HURRICANE KATRINA

On September 8, 2005, the AFASU deployed toconduct aerial spray operations for mosquito and filthfly control in support of the FEMA Hurricane Katrinarelief effort and were officially assigned to Joint TaskForce Katrina on September 9, 2005. Two sprayaircraft, a spare aircraft, and 3 crews set up at DukeField, Florida, near Eglin AFB on the Floridapanhandle. Duke Field was chosen because it was theclosest fully-functioning military base with thelogistical capability of supporting the C-130H sprayaircraft. A total of 53 personnel were involved with theflying, entomology, maintenance, administrative,communication and life support issues relating to theAFASU response.

The extent of the damage caused by Hurricane Katrinais well known.23 High winds downed trees anddestroyed homes, while heavy rain caused extensive

The pilot of an Air Force Aerial Spray Unit C-130H airplanealigns the airplane onto the next flight line during an aerialspray mission over New Orleans, Louisiana, during post-Katrina operations in September 2005.


flooding. Storm-induced breeches in the New Orleanslevee system resulted in the catastrophic flooding ofapproximately 80% of the city. Prehurricaneevacuations had been incomplete in New Orleans andsubsequent flooding exacerbated the problem bysignificantly increasing the difficulty of relief efforts.In early September, the full-scope of damage and levelof human suffering was still unknown. News agenciesreported potential human fatalities as high as 10,000inside New Orleans, incidents of gunfire aimed atrescue aircraft,24 and that EPA water tests showed E.coli levels were 10 times above safe levels.25 Rapidmosquito and fly development was projected astemperatures reached 90°F during the day, and onlycooled into the upper 70s (°F) at night. Filth flies,which have the potential to develop quickly in the typeof habitat created in flooded New Orleans (eg, fecalcontamination, muck, trash, animal carcasses) andmove between unhygienic substrates and human food,potentially transferring harmful bacteria in the process,were considered to be the immediate insect vectorpublic health threat by public health officials. Apartfrom filth flies, an additional concern for vectorecologists was that Louisiana already had abackground of West Nile virus (WNV) circulating inmosquito pools and birds. By August 30, 2005, 40cases of WNV had been reported in Louisiana,including 4 deaths. That was already more cases inLouisiana than in all of 2004.26 By all accounts,Hurricane Katrina created enough damage to exposethe population to potential vector andnuisance mosquito feeding. In particular, theabsence of electricity, physical damage toliving structures, and the use of temporaryshelters by 200,000 displaced peoplecombined to make these individualsvulnerable to mosquito bites and potentialdisease transmission. Similarly, intensemosquito exposure to rescue, cleanup, andutility repair crews, as well as lawenforcement personnel was also projected.Thus, mosquito and fly control wasconsidered a high priority in the strategy toprotect public health.

The major crisis of the storm was theflooding of New Orleans. The recovery effortincluded a combined force from the militaryservices, as well as other federal, state, andlocal agencies. The mission of the AFASU

was to provide a stopgap measure to controlmosquitoes until local mosquito control programscould resume operations. Hurricane Katrina hadcompletely disabled normal mosquito controloperations within the entire region south of LakePontchartrain. The damage ranged from various levelsof equipment damage to the destruction of entirefacilities. In one unusual example, spray trucks fromOrleans Parish were pressed into service by an ArmyNational Guard Unit. Further, employees of localMosquito Control Districts (MCD) were themselvesdisplaced by the storm. Air Force spray assetsprovided aerial vector control until MCDs could regaintheir normal operations or contracts could beestablished with private applicators. An additionalcomplicating factor for nonmilitary aerial applicatorswas that the region had been designated as militarycontrolled airspace, making spray activities by privateapplicators impossible at times.

The performance of aerial spray operations in andaround New Orleans was complicated. The AFASUpreviously conducted spray operations during federallydeclared disasters but the situation in New Orleans wasparticularly challenging. To determine the vectorthreat, entomologists from the Louisiana Departmentof Health, CDC, and Air Force visited areas in andaround New Orleans, conducted mosquito landingcounts, surveys for filth flies, and directly consultedwith bivouacking Army and Navy Preventive

An Air Force Aerial Spray Unit C-130H airplane during a vectorcontrol mission over New Orleans, Louisiana, September 2005.




Medicine Troops. This was the most effective meansof evaluating the insect vector potential because thestorm had severely limited communication betweenorganizations conducting vector surveillance.Telephone and email service was erratic and troopscontinued to move around. In some cases, troops haddeployed with insect surveillance equipment but hadno time to put it to use because of higher priority tasks.Driving in New Orleans was difficult since many roadswere still flooded or obstructed by debris. Also,military and police checkpoints were frequent. Thefew vehicles on the roads were limited to firstresponders—military, police, rescue, and utility repair.This was actually fortunate since few intersections hadfunctioning traffic lights and general disrepair existedthroughout the area. By driving to forward locations,surveillance data was gathered from Army and AirForce personnel from the Louis Armstrong Airport andNavy personnel from the Naval Air Station.

FLY CONTROL IN NEW ORLEANS

Timing insecticide applications with the period ofmaximum exposure of the target pest is a criticalcomponent of any pest control operation. Fly controlbegan 3 hours before sunset to correspond with thediurnal activity of flies but avoid the warmest part ofthe day. Fuselage booms were equipped with 6stainless steel flat fan TeeJet nozzles (size 8008)(TeeJet® Technologies, Wheaton, Illinois. 630-665-5000). Delivered by C-130H airplanes from a height of150 feet above ground level using 1,000 foot wide laneseparations (swath width), the organophosphateinsecticide Dibrom Concentrate® (AMVAC ChemicalCorporation, 4100 E Washington Blvd, Los Angeles,California, 90023) was applied at a rate of 1.0 fl oz peracre, as requested by the State of Louisiana Office ofPublic Health. Applications were made in OrleansParish on 13 and 14 September, and again on 21 and27 September, 2005.

Fly populations were monitored at 6 locations inOrleans Parish prior to the aerial spray mission on 21September by the use of sticky fly paper outdoors forapproximately 24 hours. Unfortunately, post-spraysurveillance was not possible because military supportfor this activity had been evacuated in advance ofHurricane Rita. Nonetheless, entomologists on theground in the New Orleans French Quarter observedheavy mortality in flies (sarcophagids, muscids,calliphorids, etc) within 15 minutes following the

spray application. Flies that were resting on the sidesof buildings or especially in trees near garbage pileswere more impacted by the application than those fliesunder canopies or crawling around under the trashbags/piles. Environmental parameters were recorded aspartly cloudy skies, light steady wind, 3 to 6 knotsfrom the south and south-southwest, and temperaturesranging from 88°F to 82°F with no inversion layers.Such conditions are generally considered excellent foran aerial application. Preseley et al27 found lownumbers of muscid flies and mosquitoes in OrleansParish during samples taken from 16 to 18 September,which may be testament to the success of these sprays.Aerial applications of Dibrom have been utilizedagainst flies following hurricanes since 1961.28 AfterHurricane Camille, Dubose29 reported mortalities incaged flies between 49% and 95%, where the lowerrange represents cages in protected locations versushigher mortalities from cages in exposed areas. It isassumed similar mortality rates occurred during theseapplications in Orleans Parish.

MOSQUITO SPRAYS BEYOND NEW ORLEANS

Mosquito sprays were also highly successful outside ofthe greater New Orleans area. In these cases, Dibromwas used at 0.5 to 0.75 fl oz/acre, depending onmosquito population densities. Flat fan nozzles (TeeJet8005) were used on airplanes flying a lane separationof 2,500 feet. Lane separation was dropped to 1,500feet in low wind conditions (<5 mph). Release altitudewas 150 feet above ground level for all applications.

In Acadia Parish (September 29) the primary pestmosquitoes were Psorophora columbiae (Fabr.) andPs. ciliata (Dyar & Knab) as determined by AcadiaParish Mosquito Control personnel who measuredlanding rates of these vicious biters at an average of 49per minute (range 10 to 200, 22 sites). Wind was fromthe north at 6 to 8 knots, temperature was 84°F, andrelative humidity was 60%. The spray applicationbegan 2 hours prior to sunset. A total of 169,764 acreswere sprayed. An 88% reduction in mosquito landingrates was observed at these same locations thefollowing day. This level of reduction was consideredto be a borderline success since landing rates were stillnoticeable. In parish areas not sprayed, averagelanding rates were higher than the previous day (91 perminute; range 30 to 200, 22 sites). In response toincreasing mosquito densities and the incompletecontrol from the September 29 spray mission, the


application rate was increased from 0.5 fl oz/acre to0.75 fl oz/acre on 30 September. Environmentalconditions were nearly the same as the previous night,northerly wind at 4 to 6 knots, temperature 84°F,relative humidity 60%. Again, spraying commenced 2hours prior to sunset and a total of 139,156 acres weresprayed. Excellent control was achieved from theSeptember 30 spray mission, and post-applicationlanding counts were reduced on average by 99%(range of percent reduction 95% to 100%).

In all, a total of 1,942,607 acres in the following 12Louisiana parishes were sprayed for vector andnuisance mosquitoes by the AFASU:

Increasing availability of private contractors,restoration of electrical power, and the assumption ofnormal mosquito control activities by MCDs led theLouisiana State Office of Public Health to release theAFASU on October 10, 2005. Additional AFASUspray missions continued in the state of Texas, where atotal of 938,015 acres were treated.30 As shown inTable 1, the combined total of 2,880,622 acres was thelargest area treated since the AFASU was transferredto the Air Force Reserves.

CONCLUSION

The AFASU response to Hurricanes Katrina and Ritaeffectively illustrates why the unit was formed—toeffectively minimize the occurrence of vectors andnuisance pests by treating large areas where suchpopulations exist. This activity also demonstrates theneed for military aerial spray assets in domesticsituations where local vector control agencies wereincapacitated or overwhelmed, and use of contractaerial spray assets was unfeasible because of severeairspace restrictions.

This deployment of assets was not done in a void.Without the assistance of state and federal agenciesand their personnel, the deployment would have beenextremely difficult, if not impossible. In fact, MCDs,state health agencies, and aerial spray contractors borethe brunt of public health and vector control activities

following the AFASU’s stand down andredeployment. However, this event demonstrates theAFASU’s ability to fill a “stopgap” role in domesticemergencies such as that which followed HurricanesKatrina and Rita, and its importance in civilian andmilitary contingencies.

ACKNOWLEDGEMENT

The authors thank the Acadia Parish Mosquito Controlagency which provided landing counts for AcadiaParish before and after aerial spray missions, and CPTKurt Kresta, MS, USA, for his efforts in the samplingof filth fly densities. We also extend a special thankyou to the AFASU aircrew members and maintenanceand support personnel for their unwaveringprofessionalism and dedication to ensuring the successof these very important missions.

REFERENCES

1. Hays CW. The United States Army and malariacontrol in World War II. Parassitologia. 2000;42:47-52.

2. Parrish DW, Hodapp CJ. Biological evaluation of theC-47 aerial spray system for adult mosquito control.Mosq News. 1962;22:36-37.

3. Knapp FW, Pass BC. Low-volume aerial sprays formosquito control. Mosq News. 1966;26:22-25.

4. Service MW. 2000. Medical Entomology forStudents, 2nd Ed. Cambridge UK: University ofCambridge Press.

5. World Health Organization. Space spray applicationof insecticides for vector and public health pestcontrol: A practitioner’s guide. Geneva, Switzerland:World Health Organization; 2003.

6. Dowell F. An examination of United States Air Forceaerial spray operations. Mosq News. 1965;25:209-216.

7. Scheer CJ. Aerial spraying…Air Force style. WorldAgric Aviat. 1975;2:12-13,23-30.

8. Wright RE, Knight KL. Effect of environmentalfactors on biting activity of Aedes vexans (Meigen)and Aedes trivittatus (Coquillett). Mosq News1966;26:565-578.

9. Mount GA. Optimum droplet size for adult mosquitocontrol with space sprays or aerosols of insecticides.Mosq News. 1970;30:70-75.

AcadiaAscensionBeauregardCalcasieu

JeffersonOrleansPlaqueminesSaint Bernard

TangipahoaVermilionVernonWashington




10. Breidenbaugh M, Olson S, Spears B, Teig D. Emer-gency mosquito control after Hurricane Floyd. WingBeats Fla Mosq Control Assoc. 2000;11(3):36-38.

11. Mason J, Cavalie P. Malaria epidemic in Haitifollowing a hurricane. J Trop Med Hygen.1965;14:533-539.

12. Gagnon AS, Smoyer-Tomic KE, Bush ABG. The ElNiño southern oscillation and malaria epidemics inSouth America. Int J Biometeorol 2002;46:81–89.

13. Balluz L, Moll D, Diaz Martinez MG, MeridaColindres JE, Malilay J. Environmental pesticideexposure in Honduras following Hurricane Mitch.Bull WHO. 2001;79:288-295.

14. Campanella N, Tarantini F. Incidence of someinfectious diseases in an area of Nicaragua seriouslyaffected by Hurricane Mitch. Ig Mod. 2000;113:209-223.

15. O'Leary DR, Rigau-Pe´Rez JG, Hayes EB, VorndamAV, Clark GG, Gubler. DJ.. Assessment of DengueRisk in Relief Workers in Puerto Rico after HurricaneGeorges, 1998. Am J Trop Med Hyg. 2002;66:35–39.

16. United Press International. Hurricanes help stop WestNile virus. Physorg.com [serial online] January 23,2006. Available at: http://www.physorg.com/news10152.html. Accessed July 2, 2006.

17. Neergaard L. West Nile beginning its summerassault. Las Vegas Sun. June 26, 2006. Available at:ht tp: / /www.lasvegassun.com/sunbin/s tor ies/thrive/2006/jun/26/062602005.html.

18. Roos R. Hurricane Katrina sparks fears of diseaseoutbreaks. CIDRAP News [serial online]. September2, 2005. Available at: http://www.cidrap.umn.edu/c i d r a p / c o n t e n t / f s / f o o d - d i s e a s e / n e w s /sep0205hurricane.html. Accessed July 2, 2006.

19. Hopper L. Rita's pesky offspring are here and they'rehungry. 2005. Available at: http://www.chron.com/disp/story.mpl/special /05/ri ta /3384381.html.Accessed July 2, 2006.

20. Erickson J. Mosquito numbers explode due tohurricane flooding. Rocky Mountain News.September 13, 2005. Available at: http://www.promedmail .org/pls/promed/f?p=2400:1202:9066594965860822079::no::f2400_p1202_check_display,f2400_p1202_pub_mail_id:x,30431.

21. ProMED-mail. Mosquitoes, post hurricane, USA(07). Archive 20050918.2756: September 18, 2005.Available at: http://www.promedmail.org/pls/promed/f?p=2400:1202:9066594965860822079::no::f2400_p1202_check_display,f2400_p1202_pub_mail_id:x,30431. Accessed 8 July 2006.

22. Watson JT, Gayer M, Connolly, MA. Epidemics afternatural disasters. Emerging Infect Dis. 2007;13:1-5.

23. Manuel J. In Katrina’s wake. Environ HealthPerspect. 2006;114:A32–A39.

24. Associated Press. New Orleans mayor: 10,000 feareddead. Foxnews.com [serial online]. 2005. Availableat : ht tp: / /www.foxnews.com/story/0 ,2933,168489,00.html. Accessed July 2, 2006.

25. Fox News. Bacteria in waters 10x safe levels.Foxnews.com [serial online]. 2005. Available at:http://www.foxnews.com/story/0,2933,168790,00.html. Accessed July 2, 2006.

26. Centers for Disease Control and Prevention. Update:West Nile virus activity – United States, 2005.MMWR. 2005;54:851-852.

27. Presley SM, Rainwater TR, Austin GP, Platt SG, ZakJC, Cobb GP, Marsland EJ, Tian K, Zhang B,Anderson TA, et al. Assessment of pathogens andtoxicants in New Orleans, LA following HurricaneKatrina. J Environ Sci Tech. 2006;40:468-474.

28. Davis NA, Whipp AA, Warner WW. Control ofhouse flies with aerial sprays containing Dibrom.Proceedings of the 32nd Annual Meeting of theFlorida Anti-mosquito Association. 1961:31-33.

29. Dubose W. Aerial spray tests with caged filth flies.Mosq News. 1970;30:266-267.

30. Breidenbaugh M, Haagsma K, Olson S, Teig D,Spears B, McHugh C, Walker W, Sanders D. AirForce aerial spray operation to control adult mos-quitoes following Hurricanes Katrina and Rita. WingBeats Fla Mosq Control Assoc. 2006;17(2):7-15.

AUTHORS

Maj Breidenbaugh is Chief Entomologist, Air ForceAerial Spray Unit, 757 Airlift Squadron, 910th AirliftWing, USAFR, at the Youngstown Air Reserve Station,Vienna, Ohio.

Maj Haagsma is Research Entomologist, Air ForceAerial Spray Unit, 757 Airlift Squadron, 910th AirliftWing, USAFR, at the Youngstown Air Reserve Station,Vienna, Ohio.


POLICY DEVELOPMENT

Noise-induced hearing loss appears in literature asearly as the 16th century when a French surgeonnamed Ambroise Paré described acoustic trauma indetail when he wrote of the treatment of injuriessustained by firearms.1 Even so, the protection ofhearing would not be addressed for 3 more centuriesuntil the jet engine was invented, bringing longoverdue attention and a flurry of policy developmentaddressing the prevention of hearing loss.

In 1976, the General Accounting Office, now theGovernment Accountability Office, issued aninvestigative report.2 Thisreport identified over half ofUS government employees,including the Department ofDefense (DoD), as workingin environments withinadequate procedures foridentifying and rectifyingoccupational health hazards.Further, the report requestedthat the US Congress amendthe Occupational Safety andHealth Act3 to bring federala g e n c i e s u n d e r t h einspection control of theDepartment of Labor. As aresult, in 1978, militaryaudiologists and othergovernment employeesachieved standardization inm i l i t a r y h e a r i n gconservation with thepub l i ca t i on of DoDI n s t r u c t i o n ( D O D I )6055.12,4 which providesguidance and requirementsfor hearing conservationimplementation.

To implement DODI 6055.12, the Army published atechnical bulletin (TB MED 501, HearingConservation, now discontinued) in 1980. DODI6055.12 was updated in 1987 to implement newrequirements established by the 1983 Federal NoiseAmendment.5 The new policy identified specific roleresponsibilities within a hearing conservation programand thereby paved the way for the first enforceableregulation to be published on the subject. The new,and current, implementing guidance is Department ofthe Army Pamphlet 40-501, Hearing ConservationProgram.6 This multifaceted approach to preventionhas enjoyed many years of success until OperationsEnduring Freedom and Iraqi Freedom, as illustrated in

Figure 1. The large scalec o m b a t o p e r a t i o n schallenged this garrison-oriented prevention strategy.Figure 2 demonstrates thatthe majority of hearing lossin the Army is concentratedamong those Soldiersinvolved in combat. Dataabout the percentage ofSoldiers who returned froma combat deployment withsignificant hearing problemsin 2004 are presented inTable 1. These hearing los-ses are the direct result oftheir noise exposure, andemphasize the importance ofhearing protection for com-bat and combat training.

Annual data from theDepartment of VeteransAffairs (VA) evidenced theimmediacy for implementingchange by showing hearingas a primary disability.12-14

In 2006, the VA awarded55,864 new cases for hearing

Evolution of the Army Hearing ProgramMAJ D. Scott McIlwain, MS, USA

CPT Kara Cave, MS, USACOL Kathy Gates, MS, USA

COL (Ret) Don Ciliax, MS, USA

Figure 1. Percentage of US Army Forces CommandSoldiers classified with H3 hearing profile* orgreater, displayed by year to demonstrate themarked increase shown since the beginnings ofOperations Enduring Freedom (October 2001) andIraqi Freedom (March 2003).†

*H3 hearing profile is defined by the US Army Standards ofMedical Fitness7 as “speech reception threshold in bestear not greater than 30 dB HL, measured with or withouthearing aid; or acute or chronic ear disease.”

†Chart is a compilation of data from 3 studies.8-10 (Source:ht tp://chppm-www.apgea.army.mi l/hcp// f igurestables.aspx) and the Defense Occupational andEnvironmental Health Readiness System Data Repository,Comprehensive Hearing Threshold Database for the Deptof Defense, 2008. (Source://doehrswww.apgea.army.mil/doehrsdr/).

0

10

20

30

40

50

60

34.3

16.6 16.2

51.8

1974 1989 1994 2007

Perc

enta

ge


loss alone. Between the starts of Operations EnduringFreedom and Iraqi Freedom, compensation paymentsfor hearing loss increased by 319%. Hearing loss is thesecond most common new disability award by the VA,surpassed only by tinnitus. In 2007, hearing losscompensation reached over 1 billion dollars for apredominantly preventable injury. These figures do notaccount for service members who remain on active

duty with hearing loss or those who may losehearing in the future as a result of currenthazardous noise exposure. Furthermore, the datapresented are for primary disability only and do notinclude Veterans who have another primarydisability rating, such as an amputated limb, incombination with hearing loss or tinnitus as asecondary disability.

ACCEPTING CHANGE

Whether in peacetime or wartime, hazardous noiseexists as one of the primary occupational hazardsin the Army. The risk of noise-induced hearing lossin Soldiers has reached the highest rate in over 30years. This trend resulted from current combat

operations, increased numbers of combat armsSoldiers, extended periods of weapons training, anddeployment of new and more powerful noise sourcesfrom weapons systems, vehicles, and aircraft. USforces in Iraq and Afghanistan experienced asubstantial number of blast injuries from improvisedexplosive devices, rocket-propelled grenades, andmortar rounds. These types of explosions remain the

Table 1. Clinically diagnosed noise-induced hearing lossincidence rates among Soldiers, April 1, 2003, through March31, 2004.*

Condition Diagnosed† PostdeploymentRelated Diagnosis

(n=806)

NondeploymentRelated Diagnosis

(n=141,050)

Acoustic traumaPermanent threshold shiftTinnitusEardrum perforationH3 or H4 hearing profile

45236248

13127

(5.6%)(29.3%)(30.8%)(1.6%)(15.8%)

78639

210188

3140

(0.1%)(0.5%)(1.5%)(0.1%)(2.2%)

Any of the above 553 (68.6%) 5668 (4.0%)

*Data are from Helfer et al.11

†Diagnoses as coded in accordance with the International Classification ofDiseases, 9th Revision, Clinical Modification (US Public Health Service).

CENTCOM† 0.40%

FORSCOM* 61.57%

CENTCOM† 1.94%

FORSCOM* 51.98%

2007

2006

Figure 2. Percentage of Soldiers in FORSCOM* and CENTCOM† who tested at H2‡ and H3§ or greater hearingthreshold levels in 2006 and 2007.** Overall, a much larger percentage of FORSCOM Soldiers are involved incombat operations, and the corresponding impact on hearing loss is clearly reflected in the data.

*Army Forces Command†Army Central Command‡Audiometer average level for each ear at 500, 1000, 2000 Hz, or not more than 30 dB, with no individual level greater than 35 dB at

these frequencies, and level not more than 55 dB at 4000 Hz; or audiometer level 30 dB at 500 Hz, 25 dB at 1000 and 2000 Hz,and 35 dB at 4000 Hz in better ear. (Poorer ear may be deaf).

§H3 hearing profile is defined by the US Army Standards of Medical Fitness7 as “speech reception threshold in best ear not greaterthan 30 dB HL, measured with or without hearing aid; or acute or chronic ear disease.”

**Chart is a compilation of data from 3 studies.8-10 (Source: http://chppm-www.apgea.army.mil/hcp//figurestables.aspx) and theDefense Occupational and Environmental Health Readiness System Data Repository, Comprehensive Hearing Threshold Database forthe Dept of Defense, 2008. (Source://doehrswww.apgea.army.mil/doehrsdr/).


single largest cause of injury from Operation IraqiFreedom and comprise 47% of all medicalevacuations.15 As a result, developments in protectingSoldiers from these types of hazards are paramount.

The Combat Arms Earplug (CAE) is a nonlinearearplug that allows effective communication andsituational awareness whileproviding protection fromhazardous impulse noises.Introduced to the military by thestart of Operation EnduringFreedom, Soldiers shunned themf o r o p e r a t i o n a l u s e .Astonishingly, they were alsoconsidered cost prohibitive by theunits at approximately $6 per pair.With units’ strengths decreasingbecause of hearing loss, in 2004the military began issuing CAEsto all deploying Soldiers andMarines. In fact, the MarineCorps was so convinced of theconcept that they ordered over20,000 pairs in 2004, temporarily

depleting the entire national stock of CAEs. Anecdotalinformation from audiologists who served in Iraqindicated that no Soldier seen at a combat supporthospital who reported that he or she was wearing theCAE when exposed to an explosion had rupturedeardrums.16 The CAE is now a rapid fielding issueitem for deploying Soldiers. The CAE allows most

speech information to passthrough with minimal attenuation,while protecting against noiseassociated with combat events.The CAE will soon become astandard issue item for all initialentry Soldiers, allowing them totrain with the CAE prior to usingthem in combat.15

Army Audiologists have beenserving with combat supporthospitals in Iraq since January2004. Providing these reactiveservices in theater was logical, butthe concept was not wholly soundbecause it neglected the need forprevention and maintenance of

The Combat Arms Earplug(Image courtesy of Aearo Technologies, 5457W. 79th Street, Indianapolis, IN 46268)

Tactical Communication and Protective System

The obstacle of protecting hearing while enhancing a Soldier’s communication ability and situationalawareness is being addressed by a new generation of hearing protection. This new category of equipment isknown as the tactical communications and protective system (TCAPS). TCAPS introduced a new category ofelectronic hearing protection that utilizes active noise reduction to soften noise, thus enhancing speechdiscrimination, while at the same time providing a noise reduction rate of up to 40 dB. In addition to beinglight and rugged, TCAPS devices provide protection and allow Soldiers to monitor environmental sounds,communicate, accurately gauge auditory distance, and localize sound sources without hindrance. Furthermore,some of these devices allow processing of military specific radio connections without signal interruptionwhile reducing environmental sounds. QUIETPRO® (Nacre US Inc, 106 Bud Place, Aberdeen, North Carolina28375), one of the TCAPS devices, is a rapid equipping forceitem. It allows both hearing enhancement and protection. Theresponse from Soldiers has been extremely favorable, in fact,anecdotal information indicates that they do not want to deploywithout them.

Also, Soldiers of the 4th Infantry Division, 3rd Brigade CombatTeam are receiving QUIETPRO devices to use during theirimpending Operation Iraqi Freedom deployment. Audiologistsare working closely with the 3rd BCT leadership to ensure thatthe devices are properly fitted to Soldiers, and they are trainedon the devices. In addition, all Soldiers are providedpredeployment hearing services, which include a predeploymentaudiogram, earplug fitting, and a health education briefing. Quietpro® TCAPS Device

(Photo courtesy of Nacre US, Inc.)

Evolution of the Army Hearing Program



Soldier hearing readiness while in a forwarddeployed environment. The paradigm of whatcomposed a comprehensive hearing conservationprogram in the past has shifted, and nowconsiders the Soldiers’ environment on thebattlefield. Operational hazardous noise situationsthat involved large military-unique equipment,lengthy work days, and immature infrastructure ofbase camps are addressed. Urban terrain—such asthe streets of Baghdad—is a particular hazard forSoldiers because it is wrought with obstacles suchas buildings, alley ways, and ditches. Tocompound the importance of good hearing,civilian inhabitants must be distinguished fromactual combatants in an often chaoticenvironment.

A study was conducted by the US Army HumanEngineering Laboratory in 1990 to investigate theeffects of communications on performance.17 Theexperiment, involving 30 experienced tank crews,required crews to conduct gunnery scenarios undercommunication conditions ranging from very good toextremely poor. Performance measures were recordedin different levels of speech intelligibility for eachscenario, based on the modified rhyme test (astandardized intelligibility test). Five levels of speechintelligibility were used: 100%, 75%, 50%, 25%, and0% intelligible. The specific measures used to evaluateperformance as a function of speech intelligibilitywere mission time, mission completion, missionerrors, and gunner accuracy. The scenarios consistedof 10 missions, each requiring the commander toinstruct the gunner to shoot at up to 3 targets (21targets per scenario). Four targets (tank, truck,helicopter, or troops) appeared during each mission.As is the standard operating procedure for armoroperations, it was the commander’s task to instruct thegunner to shoot at the appropriate target with theappropriate weapon. The results, displayed in Table 2,are compelling for the argument that themultidimensional sense of hearing provides anindispensable amount of information and could meanthe difference between life and death on the battlefield.

THE ARMY HEARING PROGRAM

The Army had to develop the means to prevent noise-induced hearing loss in Soldiers while ensuring theirmaximum combat effectiveness in training and duringdeployments. As a result, a contemporary model calledthe Army Hearing Program (AHP) was established.

The AHP provides prevention services in a more fluidenvironment than that experienced in garrison.

As the Army transforms, the AHP will better meet theneeds of Army civilians and Soldiers in allenvironments, especially those where the traditionalhearing conservation approach does not. The AHP, anoperational approach, provides hearing services toSoldiers in their training and operationalenvironments. The AHP consists of 4 major elements:hearing readiness, clinical hearing services,operational hearing services, and hearing conservation.This combination of services promotes and increasesSoldier awareness of hearing, and the importance ofmaintaining normal hearing for good situationalawareness and voice communication in anyenvironment, including combat. Due to current combatoperations, the risk of Soldiers incurring noise-inducedhearing loss is greater now than it has been in 30 years.Hazardous noise is one of the primary occupationalhazards in the Army. As a result, AMEDD addedauthorizations for 10 badly needed Army Audiologistsin 2007. These positions will have a positive impact onthe Army Hearing Program, but will still place theinventory at a point that is one-third lower than it wasin 1990.

Hearing services continue in the combat supporthospital in support of Operation Iraqi Freedom. Theprevalence of acoustic trauma is high in the combattheater, and commanders cannot afford to lose Soldiersto a medical evacuation for several weeks to determinetheir hearing status. In order to ensure hearing-injuredSoldiers are provided immediate care, hearing siteshave been established at all major forward operatingbases in Iraq. Soldiers receive immediate hearing care

Function Good WordIntelligibility

Poor WordIntelligibility

Time Required to Identify Target 40 Seconds 90 Seconds

Incorrect Command Heard 1% 37%

Correct Target Identification 98% 68%

Correct Targets Engaged 94% 41%

Incorrect Target Engaged 0% 8%

Table 2. Results of the US Army Human Engineering Laboratorystudy of communication on performance of tank crews undersimulated battlefield conditions (1990).

Data from Garinther and Peters.16


and follow-up services in-theater, and are quicklyreturned to duty.

CONCLUSION

Army-wide implementation of the AHP requiresadditional hearing resources to ensure both clinical andnonclinical hearing services are provided to Soldiers.In September 2006, hearing readiness was included inthe Readiness Module of the Medical ProtectionSystem. Commanders and medical leaders can nowmonitor individual and unit compliance. Hearingreadiness compliance for active duty Soldiers iscurrently 74%, a 15% increase since September2006.15 Funding is projected to fully implement AHPto bring hearing conservation into the 21st century,meeting the challenges of today’s battlefield and thatof the foreseeable future. The Army will no longeraccept hearing loss as an inevitable byproduct ofmilitary service.

REFERENCES

1. Nuland S. Doctors: The Biography of Medicine. NewYork; Vintage Books: 1988.

2. US General Accounting Office. Hazardous WorkingConditions in Seven Federal Agencies. Washington,DC: US General Accounting Office; 1976;Publication HRD-76-144: 1-104.

3. Occupational Safety and Health Act of 1970, Pub LNo. 91-596, 84 STAT. 1590 (1970).

4. Department of Defense Instruction 6055.12: DoDHearing Conservation Program (HCP). Washington,DC: US Dept of Defense; March 5, 2004.

5. Occupational Noise Exposure; Hearing ConservationAmendment; Final Rule. Fed. Reg. 48:9738-9785,Mar. 8, 1983.

6. DA Pamphlet 40-501: Hearing ConservationProgram. Washington, DC: US Dept of the Army;December 10, 1998.

7. Army Regulation 40-501: Standards of MedicalFitness. Washington, DC: US Dept of the Army;December 14, 2007: 80.

8. Walden BB, Prosek RA, Worthington DW. ThePrevalence of Hearing Loss Within Selected U.S.Army Branches. Washington, DC: US Army MedicalResearch and Development Command, US Dept ofthe Army; August 31, 1975:1-49.

9. Ohlin D, Aspinall KB, Monk WH. Hearingconservation in the U.S. Army. Army Med Dept J.Fall 1994:38-42.

10. Ohlin D. U.S. Army hearing conservation programyields cost avoidance from reduced veterans hearingloss disability. USACHPPM Today. 1995;2(2).

11. Helfer T, Jordan N, Lee R. Postdeployment hearingloss in US Army Soldiers seen at audiology clinicsfrom April 1, 2003, through March 31, 2004. Am JAudiol. 2005;14(2):161-168.

12. US Army Center for Health Promotion andPreventive Medicine. Veterans’ compensationreports. 2007. Available at: http://chppm-www.ap gea .a rmy.mi l /hcp / / reso urces /2006_veterans_compensationchart .ppt. AccessedSeptember 6, 2007.

13. US Army Center for Health Promotion andPreventive Medicine. Veterans AdministrationDisability Report. 2007. Available at: http://chppm-www.ap gea .a rmy.mi l /hcp / / reso urces /2006_vadisabilityReport.ppt. Accessed September 6, 2007.

14. US Army Center for Health Promotion andPreventive Medicine. Cost effectiveness of hearingconservation programs. 2007. Available at: http://chppm-www.apgea.army.mil/hcp//costeffective.aspx.Accessed September 6, 2007.

15. Gates K. Operational hearing services. MilitaryAudiology Short Course presented at: AnnualMeeting of Military Audiology Association; April 18,2007; Denver, CO.

16. McIlwain DS. Audiology in Operation IraqiFreedom. Audiol Today. 2004;16(5):24-25.

17. Garinther GR, Peters LJ. Impact of communicationson armor crew performance. Army Res Dev AcquisBull. January-February 1990:1-5.

AUTHORS

MAJ McIlwain is an instructor and course writer in theDepartment of Preventive Health Services at the ArmyMedical Department Center and School, Fort SamHouston, Texas.

CPT Cave is Chief of the Fort Bliss Hearing Program atthe William Beaumont Army Medical Center, FortBliss, Texas.

COL Gates is the Audiology and Hearing ProgramConsultant to The Army Surgeon General. She is alsothe Proponency Officer for Preventive Medicine, Officeof The Surgeon General, Falls Church, Virginia.

COL (Ret) Ciliax is an Army Hearing ProgramConsultant at the Center for Health Promotion andPreventive Medicine, Aberdeen Proving Ground,Maryland.

Evolution of the Army Hearing Program


An important aspect of vector-borne diseaseprevention is an understanding of how to defeat thehost–reservoir–pathogen-vector cycle through vectorsurveillance. Surveillance may lead to new orimproved vector identification information, revisedvector checklists and distributions, new informationabout vector bionomics, or useful aspects of host-reservoir-pathogen-vector interactions. Over the pastdecade, Army entomologists and their Koreancollaborators have significantly increased surveillancestudies to update knowledge and answer questionsabout vector-borne disease impacts on potentialmilitary operations in the Republic of Korea (ROK).

The studies have attempted to increase our knowledgeof pathogen-vector-host-reservoir relationships,primarily in terms of vector identification andbionomics, host behavior, geographical and seasonaldistributions, and potential control or mitigationsolutions. Vector surveillance is further augmented byhuman epidemiological investigations that identifyhuman populations at risk, and disease distributionsthat can be correlated with relative vector importance.Country-specific knowledge was acquired throughthese studies to explain the human side of diseaseacquisition. Portions of this article condense the resultsof selected vector surveillance programs of the 18thMedical Command (MEDCOM), Yongsan, Korea,but, more importantly, focus on understanding Korea-specific disease issues.

MALARIA

During the Korean War, annual malaria rates rangedfrom 8.3 to 39.2 per 1,000 Soldiers.1 In 1979, afteryears of eradication efforts, the World HealthOrganization (WHO) declared the ROK to be malariafree.2 However, in 1993, a Korean soldier based nearthe demilitarized zone (DMZ) who had no recenttravel history was diagnosed with vivax malaria.3 Thiscase was identified as autochthonous transmission thatrapidly spread throughout the ROK troops stationed

along the DMZ, and subsequently to local civiliancommunities. Based on WHO reports, North Koreaexperienced a similar resurgence of malaria, especiallyalong the DMZ. While it was thought malaria in theROK originated from North Korea, it soon becameevident that malaria was again endemic in the ROK.3-5

The Table presents the number of malaria casesreported annually in the ROK since 1993.

While malaria remains concentrated along the DMZ innorthern Gyeonggi Province, other areas of the ROKare being affected as ROK veterans return to theirhomes and develop malaria resulting from latent liverstages.6-8 Consequently, malaria spreads throughoutthe peninsula. In similar fashion, Koreans visitingnorthern Gyeonggi Province may acquire the disease,and then return to their home, elsewhere in Korea,after which the disease is expressed.6-8 If the infectiveperson (demonstrating fevers and chills) waits severaldays before seeking medical attention and is fed uponby vector mosquitoes, a focal point for malaria mayhave been created, and it may or may not survive forsuccessive transmission or seasons.

In order to determine where malaria occurs, especiallyin military or transient populations, one mustdetermine where the infective mosquito fed upon theaffected person. Since it takes from 12 days to a yearfor vivax malaria to express disease (blood stageparasites), the locations of where the disease wasexpressed and where it was acquired are oftencompletely different, especially among Soldiers whotrain along the DMZ, then return to their home base orare redeployed to the US or other countries. Therefore,detailed patient interviews by preventive medicinepersonnel trained in conducting epidemiologicalinvestigations/interviews are essential for quality datacollection and determination of the site oftransmission/infection. To achieve this, selectedpersonnel in the Force Health Protection staff, 18thMEDCOM, conduct interviews and record and analyze

Perspectives of Malaria and JapaneseEncephalitis in the Republic of Korea

LTC William J. Sames, MS, USAHeung-Chul Kim, PhD

COL (Ret) Terry A. Klein, MS, USA


these data for all US military malariacases diagnosed in the ROK.

Personnel who do not regularly workmalaria issues may assume the area ofdisease expression is where the diseasewas acquired. This has lead to theimplementation of corrective actions inthe wrong area. For example, vectorcontrol actions may be implemented inareas with few vectors, and warningsmay be given to bases or communitieswhere malaria is very low risk. In otherinstances, unit leaders may think thatthey had a successful training eventbecause no one contracted malariaduring the event. However, they do notassociate future disease expression as theresult of inadequate protection, whichmany times can be traced back to thelack of command emphasis on personalprotective measures (PPM) during theirtraining event. The delay in the onset ofsymptoms blurs the direct cause-consequence relationship. Therefore,most people fail to associate theirfailures in protective actions with theconsequences of contracting the disease.

Anopheles mosquitoes overwinter aseggs or nulliparous females (unfedfemales without eggs), which do not become infecteduntil they feed on a person with circulating parasites.Therefore, the annual vivax malaria cycle is onlymaintained by a pool of latent malaria cases andasymptomatic carriers. As the temperature warms inlate April to early May, the overwintering femalemosquito takes a blood meal and lays eggs 3 to 5 dayslater with resultant increasing vector populations.These noninfected vector mosquitoes bite personsexpressing the latent form of malaria, or untreatedindividuals who no longer demonstrate symptoms butharbor infective parasites, which in turn infect the newuninfected vectors. The vector population continues toincrease throughout the summer and interactions withinfective reservoirs and susceptible hosts assure thatsome of the parasites will be acquired and transmittedby the vector.

In rural areas along the DMZ, the probability ofacquiring malaria in April or May is low, but steadily

increases with peak transmission times occurring inlate July and throughout August. During the peakperiod, the vector population is generally at its highest.Because there has been sufficient time during thisperiod for vector-reservoir interaction, it is the oldermosquito that is the dangerous mosquito (the periodfrom ingestion of the parasite to transmission is aminimum of 9 days at optimal temperatures). Drainageof the rice paddies for harvest marks the downturn ofmalaria vector populations and results in a significantdecrease in the number of malaria cases, whichtypically stop presenting in October or earlyNovember.

A number of factors, including droughts (reduction ofbreeding sites), heavy rain from monsoons andcyclones (mosquitoes washed downstream and olderadult mosquitoes killed), pesticide/herbicide usage inthe rice paddies (overhanging grasses along the banksprovide habitat) affect population levels and the mean

Number of Plasmodium vivax malaria cases reported inthe Republic of Korea (ROK) by year since 1993.

YearUS Forces

KoreaROK

MilitaryROK

VeteransROK

Civilians Total

1993 1 1 0 0 2

1994 3 18 1 2 24

1995 1 88 12 7 108

1996 14 285 25 46 370

1997 33 1,156 207 361 1,757

1998 42 1,657 1,127 1,148 3,974

1999 58 1,084 996 1,541 3,679

2000 48 1,289 1,273 1,580 4,190

2001 30 673 748 1,067 2,518

2002 48 406 472 885 1,811

2003 30 273 274 560 1,137

2004 22 158 244 424 848

2005 17 233 322 769 1,341

2006 24 311 432 1,278 2,045

2007 34 447 462 1,271 2,214

Total 405* 8,079 6,595 10,939 26,018

*Distribution: US military - 361; Korean Army augmentees to the US Army - 43;DoD civilian - 1Sources of data: Korea Center for Disease Control and Prevention, Seoul, ROK;Force Health Protection, 18th Medical Command, Yongsan Garrison, ROK.

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea



age of the population that directly impacts ontransmission levels. As many of these conditions arevariable, they affect the number of malaria cases forany given year. For example, a very late autumnduring 2006 resulted in a spike of malaria cases at theend of the malaria season and contributed to anincreased number of latent cases the following year.

Only certain Anopheles species vector malaria. Theyfeed sometime between dusk and dawn, and are oftenclassified as primary or secondary vectors dependingon their relative susceptibility to acquire salivary glandinfections and interaction with human hosts, as someare zoophilic and prefer to feed on large animals suchas cows.9,10 Until 2005, An. sinensis was consideredthe primary malaria vector in Korea, and it wasthought to be distinguished from other Anophelesspecies by morphological characters.

In 1999, while rearing progeny broods for the WalterReed Biosystematics Unit (WRBU), two of theauthors, COL Klein and Dr Kim, discovered thatmembers of one sample demonstrated characteristicsof 2 or more species. Subsequently, more progenybroods from wild-caught blood fed females werereared, and a selected fragment of the ITS2 gene wassequenced by polymerase chain reaction by a WRBUteam and a researcher from the US Army MedicalResearch Institute for Infectious Disease to determinespecies and subsequently determine if morphologicalcharacters could be applied for their identification. In2005, these teams of Army and Korean entomologistsdetermined that Anopheles sinensis and closely relatedspecies consisted of at least 5 species: An. sinensis, An.pullus, An. lesteri, plus 2 new species: An. belenrae,and An. kleini, and further demonstrated that thesespecies could not be reliably identified bymorphological characters.11

These same entomologists, working with the ArmedForces Research Institute of Medical Sciences and theKorea National Institute of Health (KNIH), implicatedAn. pullus and An. kleini as the primary vectors ofmalaria, with An. sinensis having a lesser role.10

Therefore, areas with relatively large populations ofAn. pullus and An. kleini should correlate with areasfor the highest risk of malaria. Preliminaryinvestigations, human-based surveillance, and larvaland adult surveillance studies suggest that there is avalid correlation between the numbers of malaria cases

and these primary vector populations. These studiesare also working to determine if there is a separation ofthe larval habitat between these species, so controlefforts can focus on selected habitats of greaterimportance rather than on large scale areas, which donot support large vector populations.*

JAPANESE ENCEPHALITIS

Japanese encephalitis (JE) is a viral mosquito-bornedisease that can affect the human central nervoussystem, and may be fatal or leave people with mild tosevere brain damage (neurological deficiencies). It isvectored by Culex tritaeniorhynchus in Korea andposes a greater threat south of Seoul where very largevector populations occur. Large water birds are theprimary reservoir and swine function as amplifyinghosts. Humans are considered to be dead-end hosts asthey rarely develop sufficient viremia to infectmosquitoes. The disease is prevalent where wetlandrice farming occurs, with population densities ofvector mosquitoes peaking near the end of summer andearly fall (August to early October).

Japanese encephalitis was first identified from anAmerican Soldier at Inchon in 1946.12 In 1949, JEbecame a notifiable disease and 5616 cases resulting in2729 deaths (49%) were reported. After 1950,outbreaks of several thousand cases were reportedperiodically every 2 to 3 years. The largest outbreakoccurred in 1958 with 6,897 cases. Since 1958, therewere between 2000 to 3000 cases reported annuallyuntil 1968.13

In the mid to late 1960s, the Korean governmentinstituted a massive JE immunization program forschool-aged children which significantly changed theepidemiology of JE in Korea, but not the threat. Sincethe inception of the program, the number of JE casesdropped significantly, and for most years only a fewsporadic cases (0 to 7 cases annually) have occurredover the past decade. In addition to the immunizationprogram, a vast improvement of the environment,sanitation, and a higher standard of living contributedto the reduction of JE cases.

The relative proportion of symptomatic toasymptomatic (or mild unreported) cases is 1/25 to1/1000 (and perhaps less in healthy young men), while

*See related article on page 46.


JE infections may result in severe morbidity with 10%to 30% mortality among those that demonstratesymptoms.14,15 Researchers at the Department ofDefense (DoD) Global Emerging Infections Systemand the Walter Reed Army Institute of Research arecoordinating to evaluate pre- and postdeploymentblood samples from Soldiers previously deployed toKorea to determine relative rates of transmission inlieu of no symptomatic cases reported among USSoldiers over the past 2 decades. Currently, the USprotocol in Korea for JE vaccine categorizesinoculation as voluntary upon request by theindividual.

Japanese encephalitis is maintained in the environmentthrough a mosquito–large wading bird–mosquitocycle. The principal vectors prefer to feed on birds, butwill feed on alternate hosts when birds are notavailable or when the alternate hosts enter themosquitoes’ habitat.16 Pigs serve to amplify thetransmission cycle, producing extremely high viremiasthat infect large numbers of the blood-feeding vectormosquitoes.17 Japanese encephalitis infection causesspontaneous abortion in sows about to litter. For thisreason, breeder sows are often immunized. However,because of the costs and the absence of effect onproduction, young pigs raised for slaughter are notimmunized since virus infections do not affect theirhealth or weight gain. When military personnel resideor train near vector mosquito habitats, such as ricepaddies where large wading birds are present andespecially near pig farms when JE is circulating, theyare at high risk for infection. Therefore, riskassessments conducted for JE should consider theseasonality and proximity of swine farms to USmilitary installations and training sites.

The KNIH conducts mosquito surveillance. When JEvector populations exceed 50% of the collectedmosquitoes, the KNIH issues public JE alerts, remindscitizens to use all means to protect themselves frommosquito bites, and encourages high risk groups toobtain vaccinations. However, the areas where theKorean workforce conducts sampling are often not thesame areas of interest as those of the US armed forces.

Additionally, the KNIH conducts sero-surveillance forthe presence of JE antibodies/infection fromslaughtered pigs at selected sentinel sites. The KNIHagain reports the results in public news releases, which

emphasize vaccination and PPM. However, these datado not reflect the focal infections since:

sentinel sites are limited;

only data from slaughterhouses are reported, notthe pig farm sites where the transmissionoccurred; and

pig farms are isolated and not evenly distributed.

While these data are limited, they serve as an earlywarning system. For example, prior to theimmunization program, it was observed thatapproximately 2 weeks after the pigs wereserologically positive for JE, mosquito samples wereidentified as positive, and shortly thereafter, focaloutbreaks of JE in human populations resulted.

As the structure, distribution, and concentration of USmilitary forces change in Korea in response totransformation and base closures, vector-bornediseases must be considered, for example, themovement of forces currently deployed north of Seoulto Camp Humphreys (near Pyeongtaek), which isprogrammed to become the primary US Armyinstallation on the Korean peninsula. Currently, muchof Camp Humphreys is surrounded by rice paddies—surveillance in 2005 and 2006 demonstrated largepopulations of Culex tritaeniorhynchus occurred fromAugust through early October. The demographics ofthis installation will change from a Soldier basedcommunity to a Soldier and family member basedcommunity, placing family members, including youngchildren, at risk in an area were they may be exposedto large populations of potentially infected vectors. Inaddition, 2 of 7 JE cases reported in the highlyvaccinated Korean population during 2007 residednear Pyeongtaek, suggesting that implementation of aJE vaccination program is necessary to protect thesusceptible and growing US population at CampHumphreys. Thus, constant surveillance of mosquitopopulations, their infection rates, and coordinationwith the KNIH and Korea Center for Disease Controland Prevention is necessary to delineate the risks andreduce the threat of Japanese encephalitis to USpopulations.

MALARIA AND JAPANESE ENCEPHALITISPREVENTION AND CONTROL STRATEGIES

Readiness is a key issue with US military personnel inthe ROK. The proximity and uncertainty of a rapidly




escalating enemy threat dictate that commanders andtheir Soldiers must be prepared for hostile actions and“train as they fight.” This includes the prevention ofdisease and nonbattle injuries, especially those due topreventable diseases. Command emphasis and routineimplementation of PPM is essential. It not onlydecreases the potential for malaria and JEtransmission, but also decreases the probability ofcontracting scrub typhus and multiple tick-bornediseases. It also serves as an alert to commanders forother diseases (ie, Hantaan virus), where PPM and/orother strategies must be employed.

The prevention of mosquito-borne disease in endemichigh-risk areas of the ROK requires strict adherence tothe DoD Insect Repellent System, to include themandatory use of bed nets during overnight fieldtraining events. In 2007, the Eighth Army purchasedbed nets for use by military personnel who conductedovernight events in malaria high-risk areas near theDMZ. Barracks also replaced the tent village atWarrior Base and were thought to have an additionalbenefit of preventing vectorSoldier interactions. Itwas later observed that Soldiers would gather outsideduring off-duty hours and at night in shorts and t-shirtsto socialize. Thus, their behavior exposed them topotentially infected mosquitoes, even though they allhad the means to prevent mosquitoes from biting themand getting malaria or other diseases. Therefore,human behaviors continue to serve as major riskfactors and cannot be overlooked.

Chemoprophylaxis (chloroquine with terminalprimaquine) may be used to reduce the risks ofacquiring malaria.18 While it does not preventtransmission or infection, it does reduce the reservoirpopulation (infective humans) required for thetransmission of malaria to ROK civilians and USmilitary personnel living or deployed in closeproximity to ROK bases near the DMZ. However, aneffective chemoprophylaxis program requires strictadherence to policy and observed compliance.19,20 As aresult of increasing malaria rates observed in US andROK populations in 1998, the Eighth US Army placedall US Soldiers training near the DMZ onchemoprophylaxis. Commanders apparently did notunderstand the program as there were many variations(event and situational dependent), includingnoncompliance with terminal primaquine (15 mgdaily for 14 days after the malaria season or when

departing malaria high-risk areas). This resulted in anincreased proportion of US diagnosed malaria casesbeing attributed to exposure in Korea.

Based on recommendations from the PreventiveMedicine and Entomology Consultants, Force HealthProtection, 18th MEDCOM, after 1999 thechemoprophylaxis policy was changed:

Only those Soldiers residing in malaria high-riskareas (Camp Bonifas-Joint Security Area atPanmunjom and Camp Greaves) are placed onchemoprophylaxis.

Command emphasis is placed on prevention usingPPM that includes proper wear of the uniform,impregnating uniforms with permethrin, and usingthe standard military topical insect repellents whilein field environments near the DMZ.

Efforts to combat mosquitoes with ultra low volume(ULV) or thermal foggers present several issues forUS military forces in Korea. First, for various reasons,training areas are not treated, so PPM and othermitigation strategies must be employed in those areas.Second, US bases where mosquito-borne diseases are athreat are usually surrounded by rice paddies and assuch are basically “islands” in a sea of mosquitohabitat. Third, adulticides applied by ULV areeffective over a short time and distance but do notsignificantly slow the migration of mosquitoes fromthe surrounding rice paddies. Fourth, pesticideresistance is a continual concern as some populationsof mosquitoes are resistant to at least one of thepesticides used by the Korean health officials. Thus,health departments have resorted to a “cocktail” ofinsecticides rather than one specific type. However, itis thought that most mosquito populations aresusceptible to pesticides currently used by the USmilitary, although there have been no studies toconfirm this supposition.

On bases, Soldiers tend to escape the affects of vector-borne disease because they are normally inside fromdusk to dawn, the primary mosquito feeding times.Some bases are still located in urban areas wherevector populations are low, further suggesting that thegreatest risk for mosquito-borne disease is duringovernight field training events. Planting vegetativeborders along the perimeter of installations that aresurrounded by rice paddies, then treating the


vegetation with semipersistent chemicals may reducevector populations to acceptable levels. This reductionwould occur as mosquitoes are killed when they comeinto contact with the pesticide while resting on thevegetation during their movement from off-post toareas where the Soldiers reside. Currently, none of theUS installations or field training sites have perimetervegetation that meet the requirements for barrier sprayapplication and control, and, of course, the efficacy ofthis control strategy should be tested before fullimplementation.

Additionally, larval surveillance that identifies sourcesof vector populations on or near US installations mustbe conducted. On US installations, these sites must beidentified on detailed maps to ensure controltechniques are implemented (eg, drainage of watersources and application of larvicides) to reduce vectorpopulations. If larvicides are applied to water sources,they must be surveyed periodically to ensure that theyare effective. Pre- and postsurveillance must also beconducted when pesticides are applied to control adultpopulations, especially since preliminary observationsof ULV application indicate that it is effective for lessthan one hour after application.

New Jersey light traps (NJLT) have been used formosquito collection since the end of the Korean War.These traps use light as an attractant and thereforerequire light security where they are employed. Also,due to security at US military installations, there arefew places where lights which interfere with thecollections of mosquitoes are not present. Becauselight is used as an attractant, all insects attracted tolights (ie, moths, flies, beetles) are collected, whichresults in damaged mosquito specimens that cannot beidentified. Furthermore, a killing agent is placed in thecollection chamber that rapidly kills mosquitoes,rendering them useless for virus isolation. However,newer innovative mosquito traps have been evaluatedthat do not depend upon light security, collect largernumbers of mosquitoes, and collect mosquitoes aliveso that virus infection rates can be determined.

For example, the Mosquito Magnet®, uses CO2 andheat as attractants and selectively collects mosquitoes.Octenol can be added as an attractant and acts toattract more of some species, but repels others (eg,Culex pipiens and Culex orientalis). In general, moreAnopheles mosquitoes are captured in the Mosquito

Magnets using octenol than in other mosquito traps,but the increased attraction/repellency has not beendetermined for each species. While these traps providemany advantages—portable, can be used in areaswithout electricity such as field training sites, collectlarge numbers of mosquitoes, live-capture mosquitoesin relatively good condition so they can more easily beidentified and used for virus isolations—over thestationary NJLT, they require propane (an explosivegas) and must be secured. Results of the use ofMosquito Magnets demonstrated their utility in theidentification of JE infection rates in mosquitoes ashigh as 3.3/1,000 and 0.3/1,000 at Warrior Base;thereby identifying the focal transmission andepidemic potential of this virus.

CONCLUSION

Vivax malaria and Japanese encephalitis remain validthreats to military populations in Korea. The primarythreat of malaria is north of Seoul and along the DMZ.Travel history within Korea is important inunderstanding Korean malaria issues, and leaders mustremember to determine the site of transmission and notthe site of diagnosis when implementing preventionand control measures. Recent studies have providednew information on the acute and latent forms ofKorean malaria, the identification of new Anophelesspecies, and the incrimination of potential malariavectors and their habitats.

Japanese encephalitis continues to circulate in avianand swine populations. Korean vaccination programshave significantly reduced Japanese encephalitisexpression in humans. However, with the movementof US military dependent populations to CampHumphreys, the US military Japanese encephalitisvaccination and prevention policies for this susceptiblepopulation must be reevaluated. Studies are needed todetermine practical control strategies for "islandpopulations" of susceptible hosts, such as are found onsome US military installations in Korea.

Finally, military organizations performing vectorsurveillance studies in the ROK should coordinatetheir visit with the Force Health Protection staff at the18th MEDCOM and the 5th Medical Detachment.These organizations currently have resources andcollaborations for in-country support on theidentification of vectors, rearing immature vectors to




the adult stage, information regarding malariainterviews, and collaborative support with Koreanhealth organizations and universities.

REFERENCES

1. Marshall IH. Malaria in Korea. In: Recent Advancesin Medicine and Surgery Based on ProfessionalMedical Experiences in Japan and Korea 1950-1953[professional education course, 19-30 April, 1954].Vol. 2. Medical Science Publication No. 4.Washington, DC: US Army Medical ServiceGraduate School, Walter Reed Army Medical Center;1954:270-283. Available at: http://history.amedd.army.mil/booksdocs/korea/recad2/ch6-2.htm.

2. World Health Organization. Synopsis of the worldmalaria situation, 1979. Wkly Epidemiol Rec. 1981;56:145-149.

3. Feighner BH, Pak SI, Novakoski WL, Kelsey LL,Strickman D. Reemergence of Plasmodium vivax inthe Republic of Korea. Emerg Infect Dis. 1998;4:295-297.

4. Chai IH, Lim GI, Yoon SN, Oh WI, Kim SJK, ChaiJY. Occurrence of tertian malaria in male patientswho have never been abroad [in Hangul]. Korean JParasitol. 1994;32:195-200.

5. Cho SY, Kong Y, Park SM, et al. Two vivax malariacases detected in Korea. Korean J Parasitol. 1994;32:281-284.

6. Ree HI. Unstable vivax malaria in Korea. Korean JParasitol. 2000;38:119-138.

7. Park JW, Klein TA, Lee HC, et al. Vivax malaria: acontinuing health threat to the Republic of Korea. AmJ Trop Med Hyg. 2003;69:159-167.

8. Han ET, Lee DH, Park KD, et al. Reemerging vivaxmalaria: changing patterns of annual incidence andcontrol programs in the Republic of Korea. Korean JParasitol. 2006;44:285-294.

9. Service MW. Mosquitoes (Culicidae). In: Lane RP,Grosskey RW, eds. Medical Insects and Arachnids.London, UK: Chapman & Hall; 1993:120-240.

10. Lee WJ, Klein TA, Kim HC, et al. Anopheles kleini,An. pullus, and An. sinensis: potential vectors ofplasmodium vivax in the Republic of Korea. J MedEntomol. 2007;44:1086-1090.

11. Rueda LM,. Two new species of Anopheles(Anopheles) Hyrcanus Group (Diptera: Culicidae)from the Republic of South Korea. Zootaxa.2005;941:1-26.

12. Sabin AB, Schlesinger RW, Ginder WR, MatsumotoM. Japanese B encephalitis in an American Soldier inKorea. Am J Hyg. 1947;46:356-375.

13. Sohn YM. Japanese encephalitis immunization inSouth Korea: past, present, and future. Emerg InfectDis. 2000;6:17-24.

14. Halstead SB, Grosz CR. Subclinical Japaneseencephalitis. I. Infection of Americans with limitedresidence in Korea. Am J Hyg. 1962;75:190-201.

15. Huang CH. Studies of Japanese encephalitis in China.Adv Virus Res. 1982;27:71-101.

16. Pant CP. Control of vectors of Japanese encephalitis.Geneva: World Health Organization; 1979. Availableon request [WHO/VBC/79.733] from Division ofControl of Tropical Diseases, World HealthOrganization, 1211 Geneva 27, Switzerland.

17. Burns KF, Tigertt WD, Matumoto M. Japaneseequine encephalomyelitis: 1947 epizootic. II.Serological and etiological studies. Am J Hyg 1949;50:27-45.

18. Park JW, Klein TA, Lee HC, et al, Vivax malaria: acontinuing health threat to the Republic of Korea. AmJ Trop Med Hyg. 2003;69:159-167.

19. Gambel JM, Brundage JF, Burge RJ, DeFraites RF,Smoak BL, Wirtz RA. Survey of US Army Soldiers’knowledge, attitudes, and practices regardingpersonal protective measures to prevent arthropod-related disease and nuisance bites. Mil Med.1998;163:695-701.

20. Gambel JM, Brundage JF, Kuschner RA, Kelley PW.Deployed US Army Soldiers' knowledge and use ofpersonal protection measures to prevent arthropod-related casualties. J Trav Med 1998;5:217-220.

AUTHORS

LTC Sames is assigned to the Defense LogisticsAgency, Fort Belvoir, Virginia. Previously he was theentomology consultant to the 18th Medical Command,Yongsan Garrison, Seoul, South Korea.

COL (Ret) Klein is a consultant to the 18th MedicalCommand, Yongsan Garrison, Seoul, South Korea.

Dr Kim is the Entomology Laboratory leader, 5thMedical Detachment, Yongsan Garrison, Seoul, SouthKorea.


One of the legacies of the military campaign in thePersian Gulf is the realization that the public healthtoll of a conflict is not truly known at the time thedeployment ends. Concerns regarding delayed healtheffects may extend the medical mission for years. In aJanuary 2003 Washington Post article, David Brown1

described a “new system to keep health syndromes atbay.” He noted that “the agonizing investigation ofwhat came to be known as Gulf War syndrome erodedtrust in the military, cost hundreds of millions ofdollars and consumed thousands of years of humanlabor.” Brown acknowledged that the inability of themilitary to provide answers to questions relating toexposures, troop location, false chemical alarms, andpredeployment health status among other concernsfueled a belief that

…horrible things may have occurred during the war.…military health officials and most civilian researcherswho studied the subject do not believe anything unusualor undiscovered occurred in the Gulf War to causechronic illness. This time, the military is determined tobegin and conclude the conflict with much betterinformation.

Brown also addressed the information that is beingcollected to characterize occupational andenvironmental exposures, and its potential uses.

THE EVOLUTION OF THE OCCUPATIONAL ANDENVIRONMENTAL HEALTH ASSESSMENT

Efforts to characterize occupational and environmentalhealth (OEH) exposures in deployed settings havematured substantially. During the deployment to theBalkans, health surveillance policy stressed a need toidentify health threats in theater, routinely anduniformly collect and analyze information relevant totroop health, and disseminate this information in atimely manner. US Army preventive medicinepersonnel collected air, water, and soil samples from avariety of locations, largely out of concern aboutindustrial contamination. The ambient air wasmonitored for volatile organic compounds,semivolatile organic compounds, particulate matter

less than 10 µm in diameter (PM 10), and associatedmetals. The main source of particulate was coal-firedpower plants. Sampling indicated intermittentdetections of volatile components of fuel atconcentrations that were not sufficient to produceacute health effects, and, the potential for chronichealth effects was considered minimal due tointermittent exposures at varied locations. At onelocation near a lead smelter, ambient samplingindicated elevated levels of lead. Blood lead testingwas performed to assess exposure of the KosovoPeacekeeping Forces. Fortunately, the smelterultimately closed. Nearly 600 PM 10 samples weretaken and compared to US Environmental ProtectionAgency (EPA) Air Quality Index levels. Sixty percentof the samples were in the good category, where nohealth effects are expected. Another 38% were in themoderate category, with less than 2% categorized asunhealthy for sensitive groups or unhealthy ingeneral.2 These categories and corresponding levelsare used in the US to alert the population and sensitivesubgroups such as elderly, children, and those withheart and lung disease when outdoor activity could behazardous to their health.

Limited environmental regulations allowed pollutionof surface waters with raw sewage and industrialwastes. While US forces drank bottled water, water forcooking, laundry, and showers was produced locallyby reverse osmosis water purification units and treatedmunicipal supplies. Finished water did not exceed anyof the US Environmental Protection Agency (EPA)primary drinking water standards. Soil sampling wasalso performed and compared to the EPA risk-basedguidelines, and, given the limited duration of exposure,no concerns were noted.

ANTICIPATION AND HAZARD RECOGNITION

The current OEH assessment process focuses onhazard anticipation as well as recognition. Prior to thelocation of a site, planners can request a preliminaryhazard or Phase I assessment from the Global Threat

Health Implications of OccupationalEnvironmental Health Sampling

Coleen Weese, MD, MPH


Assessment Program.* This process identifies industryand other relevant features of a location, past use andpractices, as well as available intelligence. This can beused to guide in the selection of a location, and tofocus the Occupational and Environmental Health SiteAssessment (OEHSA). One of the initial actions takenby preventive medicine personnel upon arrival at a siteis the OEHSA. This is an overview of the location thatsurveys potential health risks, samples soil and water,and investigates focal concerns such as stained soilthat might indicate a fuel spill, stored or discardedtoxic material containers, or problems from localindustry or operations. These findings are summarizedand serve as a starting point for periodic base campassessments. While the actual sampling frequency andextent may vary with the size of the camp, thelocation, or its population, a typical analysis includessoil and water samples which are analyzed forpesticides, volatile and semivolatile compounds, andmetals. Current technology analyzes for presence ofcompounds, identifies those present, and quantifies theamount. Typically, ambient air sampling, noise, andentomological and radiation surveys are alsoconducted. The results are stored in the DefenseOccupational and Environmental Health ReadinessSystem† (DOEHRS) data portal, maintained andoperated by the US Army Center for Health Promotionand Preventive Medicine (USACHPPM).‡

USACHPPM’S ROLE IN OCCUPATIONAL ANDENVIRONMENTAL HEALTH SURVEILLANCEAND SUPPORT

The USACHPPM provides consultative assistance,equipment, and analytical support to deployedpreventive medicine units. Standardized guidancedocuments and decision criteria provide a frameworkfor hazard identification, exposure monitoring, andoperational risk assessment. USACHPPM alsoprovides training on the use of technical guidance andenvironmental monitoring equipment. OEH hazarddata is archived along with the geographic location.Since 2005, ambient sampling data linked to a baselocation can be matched with a roster of the base camp

population to identify a population at risk. Presently,the USACHPPM data archives holds tens of thousandsof sample results. These may exist as spreadsheets ofdata consisting of various concentrations of unfamiliarcompounds tied to a location, without a clearconnection to a defined population at risk or knownexposure durations. Clearly, interpretation must occurbefore this information is useful for any considerationof impact to health.

During the 1990s, the USACHPPM attempted toidentify existing exposure guidelines to use forcomparative purposes. Occupational exposure valuesexist for many compounds, for example, the ThresholdLimit Values, or TLV’s, which

…refer to airborne concentrations of substances andrepresent conditions under which it is believed thatnearly all workers may be repeatedly exposed day afterday without adverse health effects.4

Some are near-effect levels based on studies ofworkers, in settings where monitoring of industrialhygiene documented exposures. Others are based onscarce toxicological data and extrapolations. As awhole, the quantity and quality of data on which theyare based varies, resulting in differing levels ofuncertainty. These occupational guidelines aretypically used to determine when a worker should beenrolled in medical surveillance. They are also used byindustrial hygienists to determine if exposure reductionis needed, and if controls, including personalprotective equipment, should be implemented. Anothersource was those guidelines created for use inenvironmental assessment and cleanup. These oftenassume a 24-hour, daily, lifetime exposure, and aretypically derived to protect children, pregnant women,and other sensitive populations. These are not effectlevels, but conservative guidelines which includesafety factors that can serve as “clean-up goals” beforelocations are considered acceptable for unrestrictedaccess, or use as a home site or park. Additionally,short term exposure guidelines exist for acute eventssuch as a chemical release. None of the guidelinesentirely address the deployment exposure scenario—a

*The Global Threat Assessment Program, a function of USACHPPM, identifies and assesses deployment OEH hazards and threatsfor worldwide priority deployment areas, both existing and planned. These assessments are used by the OEH surveillanceactivities that support the intelligence preparation of the environment during operational planning.3

†Defense Occupational and Environmental Health Readiness System is an integrated environmental, safety, and occupationalhealth application supporting Department of Defense initiatives to capture, store, and analyze the exposure history of military-related personnel throughout their life. Source: DoD Health Affairs. Available at: http://www.ha.osd.mil/peo/ritpo/ritpo_01.asp

‡Available at: https://doehsportal.apgea.army.mil/doehrs-oehs/ Authorized users only.


relatively fit, healthy force, potentially exposed 24hours per day for a roughly 12 to 15 month period orless. Additionally, sampling indicates a pointexposure, but any one individual is unlikely to be atany spot on a base camp for 24 hours per day.Therefore, existing guidelines were modified to derivethe Military Exposure Guidelines.

FROM CONCENTRATIONS TO CONCLUSIONS

Military Exposure Guidelines (MEGs), are screeninglevels for specified exposure durations, for hundreds ofchemicals in air, water, and soil. These screeninglevels are found in the USACHPPM Technical Guide230 5 and were derived from existing levels establishedby other organizations, such as the EPA, oroccupational standards, as discussed above, modifiedto fit the deployed population and time frame. As withany guideline, its use necessitates an understanding ofwhether it represents a screening level or an actionlevel. For example, when exceeded, some occupationallevels necessitate a specific action on the part of anemployer which might be to control or reduce theexposure and potentially initiate a medical action. Incontrast, screening values, such as those used by theEPA in environmental assessment, are conservativeand thus an exceedance is an indication that furtherevaluation may be necessary, that some remediationshould occur, etc. However, an exceedance is notlikely to indicate a specific medical action for anyindividual or population. Other values that have beenderived for emergency planning purposes also havesome safety factors built in, but the uncertainty isusually less, so exceedances may be associated withspecific actions. The MEGs are screening values, notaction levels, and were reviewed by the Committee onToxicology of the National Academy of Sciences aspart of the Department of Defense (DoD) approach toOEH assessment. The Committee considered themappropriate force protective screening values, useful toprovide information to a commander and to guidefurther actions. On the other hand, the Committeeagreed that MEGs were not casualty estimates and thatexceedances did not indicate that a health effect waslikely in the exposed population .6 This point is oftenmissed or misunderstood, particularly in the context ofmedical actions, documentation, and potentially long-term surveillance and compensation.

So what is the appropriate use of a Military ExposureGuideline in OEH assessment? When a contaminant is

measured above the MEG appropriate for thepresumed duration of exposure—there are short-termand long-term MEGS—there is some “space” forevaluation. This is done by looking at potential healtheffects associated with measured levels. Given that thescreening guidelines have some built-in safety factors,there may be no health effects. This step identifies thehealth severity. The next step is to examine thelikelihood of exposures and probability (number ofsamples, etc). Once a health threat has been identifiedand its health severity and probability determined, therisk is compared to others in the process of operationalrisk management, a process for identifying, assessing,and controlling risks from operational hazards,including OEH hazards.7 Risk is determined byestimating the probability and severity of a potentialadverse impact that may result from hazards due to thepresence of an adversary or some other hazardouscondition (ie, environmental contamination). Risksrange from low through extremely high. For example,the Army’s OEH hazard operational risk management(ORM) assessments for 2005 are presented in Table 1.

Leaders seek to mitigate risk by evaluating hazardsand implementing ORM options during operationalplanning. When applied by medical personnel, theORM process allows planners to include theassessment of the severity of hazards, characterize therisks in the context of the proposed operation, and theneffectively communicate the risk assessments andappropriate control measure options to thecommander. Commanders then make informeddecisions by balancing the OEH risks and otheroperational risks with mission requirements. Giventhat ORM is intended to focus on operational risk to amission, OEH exposures with acute effects and impactare weighted more heavily.

ACUTE VERSUS DELAYED HEALTH RISKS

Typically, acute exposures are characterized as highenough to cause an effect immediately, or in the shortterm (hours or days). While they are easier to measure,and easier to interpret and relate to a health effect, itmay be less likely that monitoring information existsbecause they are often unanticipated. Examples mightinclude a fuel spill impacting water, a release of metalsor other chemicals due to a fire or burning ofmaterials, or an emission from industry due to lessstringent controls or diminishing infrastructure.Hazards associated with acute effects may impact

Health Implications of Occupational Environmental Health Sampling



operations, and as such are given a higher operationalrisk than hazards with delayed effects. However, amemorandum issued by the Joint Chiefs of Staff inNovember 2007,8 introduced new hazard severitycategories for use in ORM that address both acute andchronic effects. Those severity categories arepresented in Table 2.8(pB-9) The intent was to informcommanders of the potential effects that might notimpact the operation, but which might be force healthprotection considerations. This supports the DoDrequirement to document exposures that can causelatent health effects and, when indicated, conductlong-term medical surveillance.9 It is quite difficult tomeet this requirement if a provider does not haveaccess to the data or the interpretation.

Lower levels of hazards which may pose a chronicrisk, or contribute to or cause a delayed health effectare substantially more complicated to evaluate. It ismore likely that routine, nonincident conditionsgenerate levels that are relatively low, but may onoccasion reach levels that, if sustained, could pose achronic risk. However, this requires relatively constantexposure to these levels. Levels that are not highenough to pose an acute risk, but high enough to be ofconcern for chronic exposure may or may not betypical or sustained. Additionally, defining thepopulation who would experience a sustained exposureis difficult since people move, exposure conditions aremore likely to be variable then constant, and samplingis most often intermittent. However, long term MEGs

US Unified CommandCountry Involved

Number ofORM

Assessments

Low Risk Moderate Risk High Risk

Central Command

Afghanistan 60 50 8 Ambient air based on PM10*2 Treated water quality

Djibouti, Egypt, Kenya, Ethiopia,Kyrgyzstan, Uzbekistan, United ArabEmirates, Yemen, Saudia Arabia

31 24 2 Ambient air based on PM10*2 Treated water quality

Iraq 195 125 57 PM10* and metals9 Treated water quality2 Raw water quality

2 PM10* and lead

Kuwait 37 20 16 Ambient air based on PM10* 1 Treated water quality

Qatar 11 9 2 Ambient air based on PM10*

European Command

Bosnia, Georgia, Kosovo (Serbia),Morocco

5 4 1 Raw water quality

Southern Command

Antigua, Belize, Dominican Republic,Columbia, Grenada, Guatemala,Hait i, Honduras, NetherlandsAntilles, Nicaragua, Panama

17 12 1 Water quality1 Bottled water2 Ambient air based on PM10*

Northern Command,Joint Task Force, Katrina

United States 136 133 2 Ambient air based on PM10*1 Treated water quality

Totals 492 378 92 Ambient air19 Water quality

2 Ambient air1 Water quality

*Particulate matter less than 10 µm in diameter

Table 1. US Army Occupational and Environmental Health Operational Risk Management (ORM)Assessments Performed During Calendar Year 2005.


Tabl

e2.

Ope

rati

onal

Haz

ard

Seve

rity

Rank

ing

for

Occ

upat

iona

land

Envi

ronm

enta

lHea

lth

Haz

ards

Dur

ing

Mili

tary

Dep

loym

ents

.

Desc

ription

ofTyp

es

ofH

ealth

Effect

sD

rive

rsfo

rSeve

rity

Cate

gory

*

Op

era

tio

nalS

everi

tyR

an

k

None

Neglig

ible

Marg

inal

Cri

tica

lCata

stro

phic

Acu

teE

ffec

ts†

No

effe

cts

are

antic

ipat

edFe

wex

pose

dpe

rson

nel

(ifan

y)ar

eex

pect

edto

have

notic

eabl

eac

ute

heal

thef

fect

sdu

ring

mis

sion

.Ex

pose

dpe

rson

nel

are

expe

cted

tobe

able

toef

fect

ivel

yco

nduc

tal

lba

sic

func

tions

durin

gm

issi

on

op

era

tio

ns.

Min

imal

tono

degr

adat

ion

ofab

ilitie

sto

cond

uct

com

ple

xta

sks

are

expe

cted

.

Few

expo

sed

pers

onne

l(if

any)

are

expe

cted

toha

veno

ticea

ble

acut

ehe

alth

effe

cts

duri

ngm

issi

on.

Expo

sed

pers

onne

lare

expe

cted

tobe

able

toef

fect

ivel

yco

nduc

tal

lba

sic

func

tions

durin

gm

issi

onop

erat

ions

.M

inim

alto

node

grad

atio

nof

abili

ties

toco

nduc

tco

mpl

exta

sks

are

expe

cted

.

Man

ype

rson

nela

reex

pect

edto

have

acut

edi

sabl

ing/

inca

paci

tatin

ghe

alth

effe

cts

that

requ

ire

imm

edia

tem

edic

altr

eatm

ent

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ppor

t(e

g,ar

eco

nsid

ered

casu

altie

s.)

Ther

em

aybe

limit

edn

um

bers

offa

talit

ies.

Pers

onne

lno

tex

perie

ncin

gth

ese

mor

ese

riou

sac

ute

effe

cts

are

expe

cted

toha

veat

leas

tno

ticea

ble,

butn

otdi

sabl

ing,

heal

thef

fect

s.M

any

pers

onne

lw

illha

velim

ited

abili

tyto

cond

uct

basi

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thou

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ills

may

besi

gnifi

cant

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Man

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with

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rea

cu

ted

isa

bli

ng

/in

cap

aci

tati

ng

eff

ect

sre

quiri

ngim

med

iate

and

sign

ifica

ntm

edic

alat

tent

ion

and/

orad

ditio

nal

supp

ort

for

surv

ival

.In

crea

sing

num

ber

ofde

aths

.Ex

pose

dpe

rson

nelu

nabl

eto

perf

orm

basi

cph

ysic

alan

d/or

men

talf

unct

ions

.

and/

oran

d/or

and/

oran

d/or

nota

driv

er

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ron

icE

ffec

ts‡

No

effe

cts

are

antic

ipat

edFe

wex

pose

dpe

rson

nel

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y)ar

eex

pect

edto

deve

lop

dela

yed

onse

t,irr

ever

sibl

eef

fect

s.

Man

yex

pose

dpe

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repl

ausi

bly

expe

cted

tode

velo

pde

laye

don

set,

irrev

ersi

ble

effe

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Whi

leth

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edia

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ysio

logi

cal

ca

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itie

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fin

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mm

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rsm

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der

long

term

imp

licat

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and

app

rop

riat

ely

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mun

icat

eth

ere

sulti

ngris

ks.

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chol

ogic

alim

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atio

ns

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vers

ely

imp

act

op

era

tio

ns

part

icul

arly

over

exte

nded

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pose

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ever

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iate

phys

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th.I

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fect

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ease

.




are screening values for more chronic effects and themeasured exposure would need to be sustained forlong periods. Therefore, actions can be taken to reduceor mitigate the exposure. Typically, follow-upsampling indicates that the exposure is not likely to besustained, and the long term MEG is not exceeded on along-term basis. In the event of a significant risk for adelayed health effect, efforts to identify the exposedpopulation at risk and conduct medical surveillance orepidemiological studies could be initiated.

DOCUMENTATION OF EXPOSURE AND ACCESSTO OEH EXPOSURE INFORMATION

Documentation of “significant OEH exposures” in theindividual medical record has been required byDoD9(p8) for some time. In reality, although datacollection has occurred, the content and method ofsuch documentation has been a subject of some debate.“Significant” is not defined in the document, althoughone line states that exposures “…that result in an acuteillness or that have potential to cause latent illness willbe included in the patient records of those individualsaffected or possibly exposed.”9(p12) Theaforementioned Joint Chiefs of Staff memorandumspecifies the need to document “significantoccupational and environmental exposures,” anddefines those exposures as “…exposures that willplausibly result in clinically relevant adverse healthoutcomes to exposed individuals.”8(pA-3) While it islikely that individuals who seek care for an acuteillness will have documentation in their medicalrecords, it is possible that no sampling was availablefor the incident. The requirement to include OEHexposure data related to potential delayed effectsnecessitates the assembly and summarization of long-term sampling data. OEH data files are large and donot lend themselves to inclusion like a lab slip orindustrial hygiene sample. Additionally, manyproviders believe that long-term, ambient, population-level data, as opposed to individual or personalsamples, do not belong in a medical record, but aremore appropriate for epidemiological studies. Finally,many providers are unfamiliar with the compounds

and the basis of screening guidelines and would notnecessarily be able to use the information to takespecific actions.

US Air Forces Central* created Environmental/Occupational Health Workplace Exposure data formsthat are prepared by bioenvironmental engineers andreviewed by medical personnel. As Army and AirForce units are often collocated, Army personnel havesometimes requested documentation, and the Armypreventive medicine units in the field have generatedStandard Form (SF) 600s† for some sites. An exampleof one such SF 600 for a location in Iraq is providedon page 80. A subgroup of the Joint EnvironmentalSurveillance Working Group,‡ working with the USCentral Command Surgeon’s office and preventivemedicine organizations in theater, identified the typesof entries in the SF 600 made by the military servicesto date, and is identifying the format and data elementsto promote consistency. USACHPPM has initiated aparallel procedure to create site summaries from theORM reports completed for base camps that areshorter and can be used by a physician who desiresinformation about a base camp, an interested Soldier,the US Department of Veterans Affairs, or deployedpreventive medicine units that are creating the SF600s. Additionally, full ORM reports, sample resultsby location, and other information are still accessibleto anyone with a desire or need to know through theDOEHRS. These efforts to distill and layerinformation for archiving should make the informationmanageable and useful for those who need only asummary with the identification of any concerns.Throughout the process, the identification of potentiallong-term concerns can be documented and archivedfor current or future use. As these efforts continue andprogress, providers will become familiar with the typesof OEH health risks evaluated in theatre, and can usethis information for communication with patients, andin the evaluation of individual patients. Requests forassistance and consultation can be obtained from theEnvironmental Medicine Program at USACHPPM(http://chppm-apgea.army.mil).

*The US Air Force component of US Central Command†Chronological Record of Medical Care‡The Joint Environmental Surveillance Working Group was established in 1997 by the Assistant Secretary of Defense (HealthAffairs). It serves as a coordinating body to develop and make recommendations for DoD-wide OEHS policy. The working groupincludes representatives from the Army, Navy, and Air Force OEHS health surveillance centers, the Joint Staff, other DoD entities,and VA.


REFERENCES

1. Brown D. U.S. acts to stem a Gulf War legacy –military hopes new system keeps health syndrome atbay. Washington Post. January 21, 2003:A1.

2. Environmental Surveillance Assessment No. 47-EM-2638-00, Environmental Surveillance of Kosovo,Mitrovica, Serbia, 17-20 June 2000. AberdeenProving Ground, MD: US Army Center for HealthPromotion and Preventive Medicine. Available at:http://chppm-www.apgea.army.mil/contactus.asp.

3. Kirkpatrick JS. Global threat assessment program.Army Med Dept J. April-June 2006:51-54.

4. 2007 TLVs and BEIs. Cincinnati, Ohio: TheAmerican Conference of Governmental IndustrialHygienists; 2007:3.

5. Technical Guide 230, Guide forDeployed Preventive MedicinePersonnel on Health Risk Assessment.Version 1.3. Aberdeen ProvingGround, MD: US Army Center forHealth Promotion and PreventiveMedicine. 2003. Available at: http://c h p p m - w w w . a p g e a . a r m y . m i l /documents/tg/techguid/tg230.pdf.

6. National Research Council. Review ofthe Army's Technical Guides onAssessing and Managing ChemicalHazards to Deployed Personnel.Washington, DC: National AcademiesPress; 2004:12,76-77.

7. Field Manual 3-100.12: Risk Management. FortMonroe, VA: US Army Training and DoctrineCommand; February, 2001.

8. Office of the Chairman, Joint Chiefs of Staff.Memorandum MCM 0028-07, Procedures forDeployment Health Surveillance. Washington DC:US Dept of Defense; November 2, 2007.

9. Department of Defense Instruction 6490.03:Deployment Health. Washington, DC: US Dept ofDefense; August 11, 2006.

AUTHOR

Dr Weese is Program Manager for EnvironmentalMedicine, USACHPPM, Aberdeen Proving Ground,Maryland.

An example of an environmental/occupational health workplace exposuredata form completed for a forward deployed location in Iraq.


THE US ARMY CENTER FORHEALTH PROMOTION ANDPREVENTIVE MEDICINE

SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and internationalmilitary medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps,and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewedprint medium to encourage dialogue concerning health care issues and initiatives.

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriatesubject matter expert for further review and assessment.

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personalrelationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must stateexplicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interestnotification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies themanuscript.

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for thisassistance, if any.

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have doneso in the manuscript.

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis,and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting sourcehad no such involvement, the authors should so state.

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance withthe ethical standards of the responsible committee on human experimentation (institutional and national) and with the HelsinkiDeclaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the HelsinkiDeclaration, the authors must explain the rationale for their approach and demonstrate that the institutional review bodyexplicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether theinstitutional and national guide for the care and use of laboratory animals was followed.

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Articles should be submitted in digital format, preferably an MS Word document, either as an email attachment (withillustrations, etc), or by mail on CD or floppy disk accompanied by one printed copy of the manuscript. Ideally, a manuscriptshould be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. Ingeneral, 4 double-spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format.

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articlesshould conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible.Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript. The following is a synopsis of theAmerican Medical Association reference format:

Reference citations of published articles must include the authors’ surnames and initials, article title, publication title,year of publication, volume, and page numbers.

Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition ifappropriate, place of publication, publisher, year of copyright, and specific page numbers if cited.

Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifyinginformation as possible (location, dates, presenters, sponsors, titles).

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproductionquality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Wordphoto files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Imagessubmitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of eachphotographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions andphotos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript.

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contactinformation must be included on the title page of the manuscript.

6. Submit manuscripts to:

EDITOR, AMEDD JOURNAL

ATTN: MCCS DT2423 FSH-HOOD STFORT SAM HOUSTON, TX 78234-5078

DSN 471-6301Comm 210-221-6301Email: [email protected]

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